Provider Demographics
NPI:1962720292
Name:GRICOSKI, JEANNE LORRAINE (DO)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:LORRAINE
Last Name:GRICOSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:LORRAINE
Other - Last Name:ZUKAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:300 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:ORWIGSBURG
Practice Address - State:PA
Practice Address - Zip Code:17961-2426
Practice Address - Country:US
Practice Address - Phone:570-366-1557
Practice Address - Fax:570-366-3981
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015740207R00000X
PAOT013362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102819394Medicaid