Provider Demographics
NPI:1356422711
Name:MASANQUE, JERRY (PT)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MASANQUE
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 1:11 ROCK RUN RD
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-3048
Mailing Address - Country:US
Mailing Address - Phone:609-448-8554
Mailing Address - Fax:
Practice Address - Street 1:MULTICARE THERAPY CENTER 1527 ROUTE 27
Practice Address - Street 2:SUITE 1100
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-545-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00672000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist