Healthcare Provider Details

I. General information

NPI: 1477024941
Provider Name (Legal Business Name): JAG-ONE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MOUNTAIN BLVD BLDG C
WARREN NJ
07059-2640
US

IV. Provider business mailing address

900 ROUTE 9 N
WOODBRIDGE NJ
07095-1025
US

V. Phone/Fax

Practice location:
  • Phone: 908-222-0515
  • Fax: 908-222-0516
Mailing address:
  • Phone: 201-801-7141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUANN M TEETSELL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 718-844-5350