Provider Demographics
NPI:1407107253
Name:LUSTERMAN, JOLENE NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:NICOLE
Last Name:LUSTERMAN
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 1:1503 SAINT GEORGES AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-3427
Mailing Address - Country:US
Mailing Address - Phone:732-943-2637
Mailing Address - Fax:732-943-2745
Practice Address - Street 1:1503 SAINT GEORGES AVE
Practice Address - Street 2:STE 101
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-3427
Practice Address - Country:US
Practice Address - Phone:732-943-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01489600225100000X
NY034463-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist