Healthcare Provider Details

I. General information

NPI: 1134040405
Provider Name (Legal Business Name): JESSICA KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 2ND ST
WENATCHEE WA
98801-2197
US

IV. Provider business mailing address

5342 S NEWLAND AVE
CHICAGO IL
60638-1127
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-4709
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number70133357
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: