Provider Demographics
NPI:1407455199
Name:PHALANUKORN, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:PHALANUKORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 BRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6055
Mailing Address - Country:US
Mailing Address - Phone:732-895-7283
Mailing Address - Fax:
Practice Address - Street 1:489 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6055
Practice Address - Country:US
Practice Address - Phone:732-895-7283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61209291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist