Provider Demographics
NPI:1598083263
Name:JEDRZIEWSKI, CHEZLIE T
Entity Type:Individual
Prefix:
First Name:CHEZLIE
Middle Name:T
Last Name:JEDRZIEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 E BROWNING AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2701
Mailing Address - Country:US
Mailing Address - Phone:801-414-6183
Mailing Address - Fax:
Practice Address - Street 1:1336 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2421
Practice Address - Country:US
Practice Address - Phone:801-251-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7474516-6004101YM0800X
UT747451660091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical