Provider Demographics
NPI:1821579723
Name:JERNEJCIC, ALEX AMANDA (PTA)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:AMANDA
Last Name:JERNEJCIC
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 FALMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-1349
Mailing Address - Country:US
Mailing Address - Phone:440-226-7043
Mailing Address - Fax:
Practice Address - Street 1:30 ROTHROCK LOOP STE B
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-1331
Practice Address - Country:US
Practice Address - Phone:330-666-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA09094225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant