Provider Demographics
NPI:1134404726
Name:BREWCZYNSKI, JACEK M (PHD)
Entity type:Individual
Prefix:DR
First Name:JACEK
Middle Name:M
Last Name:BREWCZYNSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2256 FOOTHILL DR
Mailing Address - Street 2:APT 114
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109
Mailing Address - Country:US
Mailing Address - Phone:248-730-6462
Mailing Address - Fax:
Practice Address - Street 1:SALT LAKE CITY HEALTH CARE SYSTEM
Practice Address - Street 2:500 FOOTHILL DRIVE (116 OP)
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist