Provider Demographics
NPI:1952593642
Name:JONGEJAN, BRAD A (DPT)
Entity type:Individual
Prefix:MR
First Name:BRAD
Middle Name:A
Last Name:JONGEJAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:4411 SAN MATEO BLVD NE STE 11
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2011
Practice Address - Country:US
Practice Address - Phone:515-217-3907
Practice Address - Fax:505-348-0063
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010271225100000X
NM225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist