Provider Demographics
NPI:1619200540
Name:LESACA, JEROME G (PTA)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:G
Last Name:LESACA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-5617
Mailing Address - Country:US
Mailing Address - Phone:201-446-6440
Mailing Address - Fax:
Practice Address - Street 1:120 CHARLOTTE PL
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2615
Practice Address - Country:US
Practice Address - Phone:201-446-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00191200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant