Provider Demographics
NPI:1396223178
Name:SIWEK, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SIWEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W LAKE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-5101
Mailing Address - Country:US
Mailing Address - Phone:989-984-6075
Mailing Address - Fax:
Practice Address - Street 1:540 W LAKE ST STE 3
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-5101
Practice Address - Country:US
Practice Address - Phone:989-984-6075
Practice Address - Fax:989-305-6038
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist