Provider Demographics
NPI:1316203896
Name:JEFF D. KAZMIERCZAK, PSY.D., P.C.
Entity Type:Organization
Organization Name:JEFF D. KAZMIERCZAK, PSY.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KAZMIERCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-412-2778
Mailing Address - Street 1:2626 FLOSSMOOR RD
Mailing Address - Street 2:2E
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1555
Mailing Address - Country:US
Mailing Address - Phone:773-412-2778
Mailing Address - Fax:
Practice Address - Street 1:19 HERITAGE DR
Practice Address - Street 2:SUITE 211
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1369
Practice Address - Country:US
Practice Address - Phone:815-933-8760
Practice Address - Fax:815-933-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X, 103TA0700X, 103TC0700X, 103TC1900X, 103TC2200X
IL071008293103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty