Provider Demographics
NPI:1194004275
Name:FAJARDO, ILEANA (DPT)
Entity Type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 AVENEL ST
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1147
Mailing Address - Country:US
Mailing Address - Phone:732-693-6788
Mailing Address - Fax:732-636-7887
Practice Address - Street 1:415 AVENEL ST
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1147
Practice Address - Country:US
Practice Address - Phone:732-693-6788
Practice Address - Fax:732-636-7887
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01384600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist