Provider Demographics
NPI:1245434307
Name:NIESET, JENNIFER MARIE (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:NIESET
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8836 TYLER BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4361
Mailing Address - Country:US
Mailing Address - Phone:440-255-9553
Mailing Address - Fax:440-255-9563
Practice Address - Street 1:8836 TYLER BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4361
Practice Address - Country:US
Practice Address - Phone:440-255-9553
Practice Address - Fax:440-255-9563
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 008742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNI4211872Medicare PIN
OHNI4211871Medicare PIN