Healthcare Provider Details

I. General information

NPI: 1659515716
Provider Name (Legal Business Name): JONATHAN RYAN JEZEQUEL D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 E 48TH ST SUITE 802
NEW YORK NY
10017-1014
US

IV. Provider business mailing address

18 E 48TH ST SUITE 802
NEW YORK NY
10017-1014
US

V. Phone/Fax

Practice location:
  • Phone: 212-245-5500
  • Fax: 212-245-5540
Mailing address:
  • Phone: 212-245-5500
  • Fax: 212-245-5540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number031316
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: