MEDICARE: MR. JACOB GERARD VAXMONSKY OTLR

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	225X00000X	Occupational Therapist	OC005082L	PA

General Provider Information

NPI Number	:	1255428223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB GERARD VAXMONSKY OTLR

Provider Business Mailing Address
First Line	:	1315 MAIN ST
Second Line	:
City	:	PORT GRIFFITH
State	:	PA
Zip	:	18640-1536
Country	:	US
Telephone Number	:	570-655-5697
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 MAIN ST
Second Line	:
City	:	PORT GRIFFITH
State	:	PA
Zip	:	18640-1536
Country	:	US
Telephone Number	:	570-655-5697
Fax Number	:

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

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	07/08/2007

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