Provider Demographics
NPI:1275707804
Name:JONGEJAN, ANTHONY G (MMP, LMT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:G
Last Name:JONGEJAN
Suffix:
Gender:M
Credentials:MMP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 WELLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31523-7067
Mailing Address - Country:US
Mailing Address - Phone:912-577-3991
Mailing Address - Fax:
Practice Address - Street 1:664 SCRANTON RD
Practice Address - Street 2:STE 101
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1945
Practice Address - Country:US
Practice Address - Phone:912-577-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT002240225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist