MEDICARE: JESSICA LEE SHUDAK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	015041	PA

General Provider Information

NPI Number	:	1609996842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LEE SHUDAK PT

Provider Business Mailing Address
First Line	:	5800 BEAR CREEK BOULEVARD
Second Line	:	P.O. BOX 348
City	:	BEAR CREEK
State	:	PA
Zip	:	18602
Country	:	US
Telephone Number	:	570-472-3769
Fax Number	:

Provider Business Practice Location Address
First Line	:	38 N MAIN ST
Second Line	:
City	:	PITTSTON
State	:	PA
Zip	:	18640-1916
Country	:	US
Telephone Number	:	570-654-0220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	07/08/2007

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