Provider Demographics
NPI:1609002344
Name:FASS, JONATHAN EDWARD (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:FASS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:053 MCKINLY LAB
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19716
Mailing Address - Country:US
Mailing Address - Phone:302-831-8893
Mailing Address - Fax:
Practice Address - Street 1:053 MCKINLY LAB
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19716
Practice Address - Country:US
Practice Address - Phone:302-831-8893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002475208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEJ1-0002475OtherSTATE OF DELAWARE