Basic Information
| Provider Information | |||||||||
| NPI: | 1821254301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIECWISZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHURETTA | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2775 SCHOENERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180177307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108618080 | ||||||||
| FaxNumber: | 6108070366 | ||||||||
| Practice Location | |||||||||
| Address1: | 2775 SCHOENERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180177307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108618080 | ||||||||
| FaxNumber: | 6108070366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT019399 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2059618 | 01 | HIGHMARK BLUE SHIELD | OTHER | 3536366000 | 01 | KEYSTONE HEALTH PLAN EAST | OTHER | 50079517 | 01 | KEYSTONE HEALTH PLAN CENTRAL | OTHER | 1960285 | 01 | AETNA HMO | OTHER | 2936928 | 01 | UNITED HEALTHCARE | OTHER | 50079517 | 01 | CAPITAL BLUE CROSS | OTHER | 9881184 | 01 | AETNA PPO | OTHER | 3536366000 | 01 | AMERIHEALTH | OTHER | 3536366000 | 01 | INDEPENDENCE BLUE CROSS | OTHER | 1568025 | 01 | GATEWAY HEALTH PLAN | OTHER | 47241 | 01 | GEISINGER HEALTH PLAN | OTHER | 1855464 | 01 | CIGNA HEALTHCARE | OTHER |