Provider Demographics
NPI:1477024941
Name:JAG-ONE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:JAG-ONE PHYSICAL THERAPY, LLC
Other - Org Name:JAG PHYSICAL THERAPY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TEETSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-844-5350
Mailing Address - Street 1:900 ROUTE 9 N
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1025
Mailing Address - Country:US
Mailing Address - Phone:201-801-7141
Mailing Address - Fax:
Practice Address - Street 1:34 MOUNTAIN BLVD BLDG C
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-2640
Practice Address - Country:US
Practice Address - Phone:908-222-0515
Practice Address - Fax:908-222-0516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty