Provider Demographics
NPI:1790208569
Name:GORMAN, JONATHAN BENNEKE
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BENNEKE
Last Name:GORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 OGDEN AVE # 2
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-1310
Mailing Address - Country:US
Mailing Address - Phone:678-576-5141
Mailing Address - Fax:
Practice Address - Street 1:2360 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5707
Practice Address - Country:US
Practice Address - Phone:678-576-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NJ20000305632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program