Provider Demographics
NPI:1003455072
Name:J MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:J MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-564-4890
Mailing Address - Street 1:668 N FOREST DR
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2047
Mailing Address - Country:US
Mailing Address - Phone:551-486-6214
Mailing Address - Fax:
Practice Address - Street 1:668 N FOREST DR
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-2047
Practice Address - Country:US
Practice Address - Phone:201-564-4890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty