Provider Demographics
NPI:1891052767
Name:CZERECH, JOLANTA
Entity Type:Individual
Prefix:
First Name:JOLANTA
Middle Name:
Last Name:CZERECH
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 1:2026 MENAHAN ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1935
Mailing Address - Country:US
Mailing Address - Phone:347-410-3938
Mailing Address - Fax:
Practice Address - Street 1:20-26 MENAHAN STREET
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:347-410-3938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY817294141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator