Provider Demographics
NPI:1073839056
Name:MARCINIAK, JACELYN ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JACELYN
Middle Name:ANN
Last Name:MARCINIAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142
Mailing Address - Country:US
Mailing Address - Phone:262-656-7500
Mailing Address - Fax:262-656-7515
Practice Address - Street 1:1519 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3954
Practice Address - Country:US
Practice Address - Phone:262-656-7500
Practice Address - Fax:262-656-7515
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1104-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant