Healthcare Provider Details

I. General information

NPI: 1407671407
Provider Name (Legal Business Name): WIKTOR JEZNACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S KING RD # 152
SAN JOSE CA
95122-2139
US

IV. Provider business mailing address

1150 S KING RD # 152
SAN JOSE CA
95122-2139
US

V. Phone/Fax

Practice location:
  • Phone: 408-622-9222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: