Healthcare Provider Details

I. General information

NPI: 1962617977
Provider Name (Legal Business Name): JEROME KOWALEWSKI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 YORK RD STE 21
LUTHERVILLE MD
21093-6211
US

IV. Provider business mailing address

2048 BRANDY DR
FOREST HILL MD
21050-3150
US

V. Phone/Fax

Practice location:
  • Phone: 410-828-6062
  • Fax: 410-298-8225
Mailing address:
  • Phone: 410-803-9696
  • Fax: 410-298-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number01088
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: