Provider Demographics
NPI:1619996931
Name:JEANTY, KIMBERLY J (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:JEANTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 ARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-8037
Mailing Address - Country:US
Mailing Address - Phone:570-730-5333
Mailing Address - Fax:570-213-0942
Practice Address - Street 1:514 JOYCE ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-1411
Practice Address - Country:US
Practice Address - Phone:570-730-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01003000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ114123TVNMedicare PIN