Provider Demographics
NPI:1174013478
Name:JETHWA, PAANERI ATUL
Entity Type:Individual
Prefix:
First Name:PAANERI
Middle Name:ATUL
Last Name:JETHWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BEACON WAY,
Mailing Address - Street 2:THE BEACON, 402 MERCURY
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304
Mailing Address - Country:US
Mailing Address - Phone:313-209-2661
Mailing Address - Fax:
Practice Address - Street 1:129 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-2811
Practice Address - Country:US
Practice Address - Phone:212-227-3233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01786500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist