Provider Demographics
NPI:1114931292
Name:JENDRISAK, EDWARD ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ANTHONY
Last Name:JENDRISAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4054 FORESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44286-9576
Mailing Address - Country:US
Mailing Address - Phone:330-659-0769
Mailing Address - Fax:
Practice Address - Street 1:4054 FORESTRIDGE DR
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44286-9576
Practice Address - Country:US
Practice Address - Phone:330-659-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT059152251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics