Provider Demographics
NPI:1255340899
Name:CIOCCA, JEFFERY LEE (PT)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:LEE
Last Name:CIOCCA
Suffix:
Gender:M
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:PO BOX 350034
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43635-0034
Mailing Address - Country:US
Mailing Address - Phone:260-343-0343
Mailing Address - Fax:260-343-0533
Practice Address - Street 1:621 W NORTH ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1009
Practice Address - Country:US
Practice Address - Phone:260-343-0343
Practice Address - Fax:260-343-0533
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003606A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200250170AMedicaid
IN200154530Medicaid
IN200250170AMedicaid
IN145240BMedicare PIN
INCG1609Medicare PIN
IN145240Medicare PIN