Provider Demographics
NPI:1447497987
Name:GANON, JESSIE (PT)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:
Last Name:GANON
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 1:4251 ROUTE 9 N
Mailing Address - Street 2:BUILDING 3 SUITE B
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-8303
Mailing Address - Country:US
Mailing Address - Phone:732-683-1800
Mailing Address - Fax:732-683-1090
Practice Address - Street 1:4251 ROUTE 9 N
Practice Address - Street 2:BUILDING 3 SUITE B
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-8303
Practice Address - Country:US
Practice Address - Phone:732-683-1800
Practice Address - Fax:732-683-1090
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01244200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist