Provider Demographics
NPI:1013058965
Name:TISEO, JENNIFER ANNE (MA, PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:TISEO
Suffix:
Gender:F
Credentials:MA, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5151
Mailing Address - Country:US
Mailing Address - Phone:631-724-4643
Mailing Address - Fax:
Practice Address - Street 1:1 BRANDYWINE DR
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5721
Practice Address - Country:US
Practice Address - Phone:631-392-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0155221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist