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General NPI Number Information
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NPI Number | 1730460502
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Entity Type | Organization
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Legal Business Name | RUN JUMP ROLL PT PLLC
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Dates
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Enumeration Date | 09/07/2011
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Last Update Date | 09/07/2011
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Provider Practice Location Address
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Address Line | 433 3RD AVE - COMMERCIAL SPACE 2
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City | BROOKLYN
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State | NY
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Zip | 11215
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Country | US
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Telephone | 917-579-0875
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Fax |
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Provider Business Mailing Address
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Address Line | 393A 14TH ST APT 2
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City | BROOKLYN
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State | NY
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Zip | 11215-5110
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Country | US
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Telephone | 917-579-0875
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Fax |
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Authorized Official
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Title or Position | PRINCIPAL
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Name | JENNIFER KAY LAING
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Credential | MS PT
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Telephone | 917-579-0875
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 023557
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License Number State | NY
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