Basic Information
Provider Information | |||||||||
NPI: | 1780021659 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAYNE | ||||||||
FirstName: | ERIKA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13A MAIN ST | ||||||||
Address2: | SUITE 4 | ||||||||
City: | SPARTA | ||||||||
State: | NJ | ||||||||
PostalCode: | 078711941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9737267400 | ||||||||
FaxNumber: | 9737267440 | ||||||||
Practice Location | |||||||||
Address1: | 4473 PINE RIDGE DRIVE BUS | ||||||||
Address2: |   | ||||||||
City: | BUSHKILL | ||||||||
State: | PA | ||||||||
PostalCode: | 183241832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6099034122 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2013 | ||||||||
LastUpdateDate: | 06/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01496200 | NJ | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | PT024152 | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | PT024152 | 01 | PA | PT LICENSE | OTHER |