Provider Demographics
NPI:1881692614
Name:SUKENICK, JEFFERY JOSEPH (PT)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:JOSEPH
Last Name:SUKENICK
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 627
Mailing Address - Street 2:
Mailing Address - City:POCONO SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18346-0627
Mailing Address - Country:US
Mailing Address - Phone:570-839-8818
Mailing Address - Fax:570-839-9140
Practice Address - Street 1:ROUTE 940
Practice Address - Street 2:FAM BROS PLAZA
Practice Address - City:POCONO SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18346-0627
Practice Address - Country:US
Practice Address - Phone:570-839-8818
Practice Address - Fax:570-839-9140
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013626L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018196280001Medicaid
PA043165Medicare ID - Type Unspecified
PA0018196280001Medicaid