Healthcare Provider Details

I. General information

NPI: 1578183497
Provider Name (Legal Business Name): JENNIFER R KAZMIERKOSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16320 S 88TH AVE
ORLAND PARK IL
60462-5608
US

IV. Provider business mailing address

16320 S 88TH AVE
ORLAND PARK IL
60462-5608
US

V. Phone/Fax

Practice location:
  • Phone: 715-415-5832
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: