Provider Demographics
NPI:1982794673
Name:PORZEMSKY, JERRY MARVIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MARVIN
Last Name:PORZEMSKY
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 1:2909 W FARGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1222
Mailing Address - Country:US
Mailing Address - Phone:773-262-5757
Mailing Address - Fax:773-262-4018
Practice Address - Street 1:2909 W FARGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1222
Practice Address - Country:US
Practice Address - Phone:773-262-5757
Practice Address - Fax:773-262-4018
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0711197103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL509410Medicare ID - Type Unspecified