Provider Demographics
NPI:1508939620
Name:KOWALSKI, JACQUELINE LOUISE (ED D)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LOUISE
Last Name:KOWALSKI
Suffix:
Gender:F
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 PURCELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45205-2344
Mailing Address - Country:US
Mailing Address - Phone:513-471-9169
Mailing Address - Fax:513-251-7922
Practice Address - Street 1:712 PURCELL AVENUE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45205-2344
Practice Address - Country:US
Practice Address - Phone:513-471-9169
Practice Address - Fax:513-251-7922
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3521103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0771795Medicaid
OHKOCP09771Medicare ID - Type Unspecified
OH0771795Medicaid