Provider Demographics
NPI:1710107172
Name:MENDALA, JACEK WLADYSLAW (PT)
Entity Type:Individual
Prefix:MR
First Name:JACEK
Middle Name:WLADYSLAW
Last Name:MENDALA
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 1:3110 N MILWAUKEE AVE
Mailing Address - Street 2:APT.3F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6622
Mailing Address - Country:US
Mailing Address - Phone:121-979-3990
Mailing Address - Fax:
Practice Address - Street 1:1866 W 85TH AVE
Practice Address - Street 2:APT. J 275
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8478
Practice Address - Country:US
Practice Address - Phone:219-793-9902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007301A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist