Basic Information
| Provider Information | |||||||||
| NPI: | 1013958818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JADCZAK | ||||||||
| FirstName: | JEFFERY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 8019 FRANKFORD AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191362786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153388900 | ||||||||
| FaxNumber: | 2153388923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J10001754 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT015518 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30051358 | 01 | PA | KEYSTONE MERCY | OTHER | 000000215642 | 01 | PA | AMERICHOICE | OTHER | P00359632 | 01 | MEDICARE RR | OTHER | 1013958818 | 01 | BRAVO | OTHER | 102406483-0001 | 05 | PA | MEDICAID | 1483149 | 01 | HIGHMARK | OTHER | 2173675000 | 01 | PA | IBC | OTHER |