Provider Demographics
NPI:1962907360
Name:BONCZEK, JARED (PTA)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:BONCZEK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BRIARHILL CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1602
Mailing Address - Country:US
Mailing Address - Phone:570-504-6036
Mailing Address - Fax:
Practice Address - Street 1:2 BRIARHILL CIR
Practice Address - Street 2:
Practice Address - City:SOUTH ABINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18411-1602
Practice Address - Country:US
Practice Address - Phone:570-504-6036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI005000225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty