MEDICARE: CHEZLIE T JEDRZIEWSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	7474516-6004	UT
2	1041C0700X	Clinical Social Worker	74745166009	UT

General Provider Information

NPI Number	:	1598083263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHEZLIE T JEDRZIEWSKI

Provider Business Mailing Address
First Line	:	1543 E BROWNING AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2701
Country	:	US
Telephone Number	:	801-414-6183
Fax Number	:

Provider Business Practice Location Address
First Line	:	1336 S 1100 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2421
Country	:	US
Telephone Number	:	801-251-6775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2010
Last Update Date	:	05/27/2022

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