Provider Demographics
NPI:1457740979
Name:CIESLAK, JEFFREY ALLEN (LAT,AT,C, EMT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALLEN
Last Name:CIESLAK
Suffix:
Gender:M
Credentials:LAT,AT,C, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34565 MEADOW VIEW CT
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-8778
Mailing Address - Country:US
Mailing Address - Phone:262-853-1629
Mailing Address - Fax:
Practice Address - Street 1:400 W RIVERWOODS PKWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-465-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0000195-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer