Provider Demographics
NPI:1255586244
Name:BROGAN, JEAN MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARIE
Last Name:BROGAN
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 1:214 HOPPER RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-2707
Mailing Address - Country:US
Mailing Address - Phone:315-492-2042
Mailing Address - Fax:
Practice Address - Street 1:214 HOPPER RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-2707
Practice Address - Country:US
Practice Address - Phone:315-492-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015213-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist