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General NPI Number Information
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NPI Number | 1598084154
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Entity Type | Organization
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Legal Business Name | JERRY PORZEMSKY, PH.D. P.C.
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Dates
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Enumeration Date | 05/21/2010
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Last Update Date | 06/24/2010
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Provider Practice Location Address
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Address Line | 2909 W FARGO AVE
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City | CHICAGO
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State | IL
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Zip | 60645-1222
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Country | US
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Telephone | 773-262-5757
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Fax | 773-262-4018
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Provider Business Mailing Address
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Address Line | 2909 W FARGO AVE
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City | CHICAGO
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State | IL
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Zip | 60645-1222
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Country | US
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Telephone | 773-262-5757
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Fax | 773-262-4018
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY MARVIN PORZEMSKY
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Credential | PH.D.
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Telephone | 773-262-5757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071001197
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License Number State | IL
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