Provider Demographics
NPI:1063564235
Name:LENNON, JASON A (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:LENNON
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 1:97 W. MONTAUK HWY
Mailing Address - Street 2:PECONIC PHYSICAL THERAPY
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946
Mailing Address - Country:US
Mailing Address - Phone:631-723-0801
Mailing Address - Fax:631-723-0802
Practice Address - Street 1:97 W. MONTAUK HWY.
Practice Address - Street 2:PECONIC PHYSICAL THERAPY
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3531
Practice Address - Country:US
Practice Address - Phone:631-723-0801
Practice Address - Fax:631-723-0802
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025827-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ28X41Medicare ID - Type Unspecified