Provider Demographics
NPI:1366620569
Name:SAN JOSE, JEROME A
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:A
Last Name:SAN JOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 78TH ST
Mailing Address - Street 2:APT. 514
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1950
Mailing Address - Country:US
Mailing Address - Phone:347-605-8285
Mailing Address - Fax:
Practice Address - Street 1:4150 78TH ST
Practice Address - Street 2:APT. 514
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1950
Practice Address - Country:US
Practice Address - Phone:347-605-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027253-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist