Provider Demographics
NPI:1053520445
Name:JEROEN KEESSEN
Entity type:Organization
Organization Name:JEROEN KEESSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:845-566-3514
Mailing Address - Street 1:1400 ROUTE 300
Mailing Address - Street 2:SUITE 9
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2995
Mailing Address - Country:US
Mailing Address - Phone:845-566-3514
Mailing Address - Fax:845-566-3518
Practice Address - Street 1:1400 ROUTE 300
Practice Address - Street 2:SUITE 9
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2995
Practice Address - Country:US
Practice Address - Phone:845-566-3514
Practice Address - Fax:845-566-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014752-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ5W4Q1Medicare UPIN