Provider Demographics
NPI:1467689422
Name:KACZOROWSKI, JESSICA A (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:KACZOROWSKI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 ELLA ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4768 PARK GRANADA
Practice Address - Street 2:SUITE 101
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302
Practice Address - Country:US
Practice Address - Phone:805-267-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26784103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist