MEDICARE: JENNIFER MARIE NIESET 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	PT 008742	OH

General Provider Information

NPI Number	:	1245434307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MARIE NIESET PT

Provider Business Mailing Address
First Line	:	8836 TYLER BLVD
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4361
Country	:	US
Telephone Number	:	440-255-9553
Fax Number	:	440-255-9563

Provider Business Practice Location Address
First Line	:	8836 TYLER BLVD
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4361
Country	:	US
Telephone Number	:	440-255-9553
Fax Number	:	440-255-9563

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	06/19/2014

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