Provider Demographics
NPI:1821390873
Name:SZYDLO, JACEK P (PTA)
Entity Type:Individual
Prefix:
First Name:JACEK
Middle Name:P
Last Name:SZYDLO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23509 CONNON RD
Mailing Address - Street 2:P.O. BOX 312
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-9777
Mailing Address - Country:US
Mailing Address - Phone:989-742-2134
Mailing Address - Fax:989-742-7581
Practice Address - Street 1:23509 CONNON RD
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MI
Practice Address - Zip Code:49746-9777
Practice Address - Country:US
Practice Address - Phone:989-742-2134
Practice Address - Fax:989-742-7581
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007503-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant