Provider Demographics
NPI:1467068809
Name:BONGIOVANNI, JEREMY DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:BONGIOVANNI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:888-830-4125
Mailing Address - Fax:
Practice Address - Street 1:608 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5170
Practice Address - Country:US
Practice Address - Phone:201-484-0134
Practice Address - Fax:201-484-7123
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NJ40QA01948700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty