Healthcare Provider Details

I. General information

NPI: 1477841427
Provider Name (Legal Business Name): JANIECE LYNN SIERACKI PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5034 NEWFOREST DR
SAN ANTONIO TX
78229-5459
US

IV. Provider business mailing address

1216 S 15TH ST
TEMPLE TX
76504-7233
US

V. Phone/Fax

Practice location:
  • Phone: 254-399-6633
  • Fax:
Mailing address:
  • Phone: 507-313-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA1251
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1564-19
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2120490
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: