Provider Demographics
NPI:1639255607
Name:MONACO, JERRY THOMAS (PT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:THOMAS
Last Name:MONACO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23-00 ROUTE 208
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-796-1138
Mailing Address - Fax:201-796-7484
Practice Address - Street 1:23-00 ROUTE 208
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-796-1138
Practice Address - Fax:201-796-7484
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01224100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ109357TJ5Medicare PIN