Provider Demographics
NPI:1902178015
Name:KAZMIERCZAK, JEFFREY DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:KAZMIERCZAK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HERITAGE PLZ
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1369
Mailing Address - Country:US
Mailing Address - Phone:815-933-8760
Mailing Address - Fax:815-933-9061
Practice Address - Street 1:19 HERITAGE PLZ
Practice Address - Street 2:SUITE 211
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1369
Practice Address - Country:US
Practice Address - Phone:815-933-8760
Practice Address - Fax:815-933-9061
Is Sole Proprietor?:No
Enumeration Date:2012-02-04
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008293103TC0700X, 103TF0200X, 103G00000X
103TA0700X, 103TC2200X, 103TC1900X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic