Provider Demographics
NPI:1760830475
Name:SOUKENIK, JACK (ATC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SOUKENIK
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 1:4707 MILL ST
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-8934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4707 MILL ST
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255-8934
Practice Address - Country:US
Practice Address - Phone:330-274-2747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0047312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer