Provider Demographics
NPI:1952049520
Name:KISIEL, JACOB MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:KISIEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2603
Mailing Address - Country:US
Mailing Address - Phone:814-864-4031
Mailing Address - Fax:
Practice Address - Street 1:5515 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-868-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2023-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT0216112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry