Healthcare Provider Details

I. General information

NPI: 1316203896
Provider Name (Legal Business Name): JEFF D. KAZMIERCZAK, PSY.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 HERITAGE DR SUITE 211
BOURBONNAIS IL
60914-1369
US

IV. Provider business mailing address

2626 FLOSSMOOR RD 2E
FLOSSMOOR IL
60422-1555
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-8760
  • Fax: 815-933-9061
Mailing address:
  • Phone: 773-412-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number071008293
License Number StateIL

VIII. Authorized Official

Name: DR. JEFFREY DAVID KAZMIERCZAK
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 773-412-2778