Provider Demographics
NPI:1174835524
Name:KOLODZIEJSKI, JESSE ANDREW (ATC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:ANDREW
Last Name:KOLODZIEJSKI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 COLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-0001
Mailing Address - Country:US
Mailing Address - Phone:478-301-2371
Mailing Address - Fax:478-301-2039
Practice Address - Street 1:1400 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-0001
Practice Address - Country:US
Practice Address - Phone:478-301-2371
Practice Address - Fax:478-301-2039
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20000039452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer