Provider Demographics
NPI:1740309087
Name:JANECEZK, AMY L (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:JANECEZK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3534 MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8239
Mailing Address - Country:US
Mailing Address - Phone:740-262-1611
Mailing Address - Fax:
Practice Address - Street 1:26 N UNION ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1922
Practice Address - Country:US
Practice Address - Phone:740-362-9641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06223225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant