Provider Demographics
NPI:1659772523
Name:KOPACK, JEFFREY MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:KOPACK
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 1:297 PASSAIC AVE
Mailing Address - Street 2:UNIT 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-2503
Mailing Address - Country:US
Mailing Address - Phone:973-227-4280
Mailing Address - Fax:973-227-4210
Practice Address - Street 1:297 PASSAIC AVE
Practice Address - Street 2:UNIT 3
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2503
Practice Address - Country:US
Practice Address - Phone:973-227-4280
Practice Address - Fax:973-227-4210
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01573400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist