Provider Demographics
NPI:1538243670
Name:FOGU, JASON THOMAS (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:THOMAS
Last Name:FOGU
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HUMPHREY AVE
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-7300
Mailing Address - Country:US
Mailing Address - Phone:201-240-4587
Mailing Address - Fax:
Practice Address - Street 1:21 -29 WEST 25TH STREET
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-7300
Practice Address - Country:US
Practice Address - Phone:201-339-4160
Practice Address - Fax:201-339-4592
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00679700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist