Provider Demographics
NPI:1073817615
Name:CULLEN-DUPONT, JESSE (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CULLEN-DUPONT
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E 84TH ST
Mailing Address - Street 2:GROUND FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2973
Mailing Address - Country:US
Mailing Address - Phone:646-841-1414
Mailing Address - Fax:
Practice Address - Street 1:245 E 84TH ST
Practice Address - Street 2:GROUND FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-2973
Practice Address - Country:US
Practice Address - Phone:646-841-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033299-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist