Provider Demographics
NPI:1649563297
Name:IANNACO, JAMIE J (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:J
Last Name:IANNACO
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 1:572 PESTLETON RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD WORKS
Mailing Address - State:NJ
Mailing Address - Zip Code:08089-2120
Mailing Address - Country:US
Mailing Address - Phone:856-767-6587
Mailing Address - Fax:
Practice Address - Street 1:429 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:ATCO
Practice Address - State:NJ
Practice Address - Zip Code:08004-2227
Practice Address - Country:US
Practice Address - Phone:856-753-1111
Practice Address - Fax:856-753-1454
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01296100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist