Provider Demographics
NPI:1295912939
Name:NICKEY, JON O (PT)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:O
Last Name:NICKEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12611 ECKEL JUNCTION RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1304
Mailing Address - Country:US
Mailing Address - Phone:877-511-9739
Mailing Address - Fax:419-745-8819
Practice Address - Street 1:12611 ECKEL JUNCTION RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1304
Practice Address - Country:US
Practice Address - Phone:877-511-9739
Practice Address - Fax:419-745-8819
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.012004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2904816Medicaid
OH2904816Medicaid
OH4227556Medicare PIN