Provider Demographics
NPI:1821169137
Name:JAZWINSKI, MARY LOU (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:JAZWINSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3902
Mailing Address - Country:US
Mailing Address - Phone:610-874-5257
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-3902
Practice Address - Country:US
Practice Address - Phone:610-874-5257
Practice Address - Fax:610-874-7241
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004739L2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA009069800Medicaid
PAE00703Medicare UPIN
PA071053Medicare ID - Type Unspecified