Provider Demographics
NPI:1700623584
Name:JEZIOR, JOHN PATRICK
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:JEZIOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12041 CREEKBEND DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-5629
Mailing Address - Country:US
Mailing Address - Phone:240-447-3114
Mailing Address - Fax:
Practice Address - Street 1:7051 HEATHCOTE VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3196
Practice Address - Country:US
Practice Address - Phone:571-755-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist