Healthcare Provider Details

I. General information

NPI: 1700134616
Provider Name (Legal Business Name): JEANNE OLINDA KOZLOVSKY APCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10335 W GLENDALE AVE
WAUWATOSA WI
53225-4634
US

IV. Provider business mailing address

10335 W GLENDALE AVE
WAUWATOSA WI
53225-4634
US

V. Phone/Fax

Practice location:
  • Phone: 262-853-0468
  • Fax:
Mailing address:
  • Phone: 262-853-0468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number127269121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: