Provider Demographics
NPI:1255836318
Name:MUCCIOLI, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:MUCCIOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 KING ST
Mailing Address - Street 2:
Mailing Address - City:PERRYOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15473-9327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 KING ST
Practice Address - Street 2:
Practice Address - City:PERRYOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15473-9327
Practice Address - Country:US
Practice Address - Phone:724-970-5998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0072722255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer