Provider Demographics
NPI:1366976698
Name:THE JACKSON CENTER FOR FOOT AND ANKLE MEDICINE
Entity type:Organization
Organization Name:THE JACKSON CENTER FOR FOOT AND ANKLE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KASZUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-833-2800
Mailing Address - Street 1:35 BEAVERSON BLVD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 BEAVERSON BLVD
Practice Address - Street 2:1
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7812
Practice Address - Country:US
Practice Address - Phone:732-477-0441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00240300332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7323107Medicaid
NJ7323107Medicaid