MEDICARE: KIMBERLY J. JEANTY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01003000	NJ

General Provider Information

NPI Number	:	1619996931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY J. JEANTY PT

Provider Business Mailing Address
First Line	:	158 ARBOR WAY
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-8037
Country	:	US
Telephone Number	:	570-730-5333
Fax Number	:	570-213-0942

Provider Business Practice Location Address
First Line	:	514 JOYCE ST
Second Line	:
City	:	ORANGE
State	:	NJ
Zip	:	07050-1411
Country	:	US
Telephone Number	:	570-730-5333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	10/03/2012

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