Provider Demographics
NPI:1790745693
Name:POLONCHEK, JEANNA SUZANNE (EDD, ATC, CPED, OT-)
Entity Type:Individual
Prefix:MS
First Name:JEANNA
Middle Name:SUZANNE
Last Name:POLONCHEK
Suffix:
Gender:F
Credentials:EDD, ATC, CPED, OT-
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CRANE AVE S
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-7232
Mailing Address - Country:US
Mailing Address - Phone:508-295-5100
Mailing Address - Fax:508-295-9467
Practice Address - Street 1:1 RECOVERY RD
Practice Address - Street 2:SUITE FOUR
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-5011
Practice Address - Country:US
Practice Address - Phone:508-295-8800
Practice Address - Fax:508-295-9467
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5788400001OtherPTAN