Provider Demographics
NPI:1376669846
Name:IACAVAZZI, JEFFREY PAUL (OTR)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:PAUL
Last Name:IACAVAZZI
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-3008
Mailing Address - Country:US
Mailing Address - Phone:570-346-7381
Mailing Address - Fax:
Practice Address - Street 1:1115 CORNELL ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-3008
Practice Address - Country:US
Practice Address - Phone:570-346-7381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOCC004402L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist