Jeffrey David Kazmierczak, PSY.D

Primary specialty

Clinical NeuropsychologistTaxonomy code 103G00000X

License

071008293 Issued in IL

Practice address

19 Heritage PLZ
Suite 211
Bourbonnais, IL 60914-1369

Phone

(815) 933-8760

Fax

(815) 933-9061

NPI assigned

Feb 4, 2012

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 7

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jan 1, 2014 through Jan 1, 2028

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1328313600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1333929600000",
    "number": "1902178015",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19 HERITAGE PLZ",
            "address_2": "SUITE 211",
            "city": "BOURBONNAIS",
            "state": "IL",
            "postal_code": "609141369",
            "telephone_number": "815-933-8760",
            "fax_number": "815-933-9061"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19 HERITAGE PLZ",
            "address_2": "SUITE 211",
            "city": "BOURBONNAIS",
            "state": "IL",
            "postal_code": "609141369",
            "telephone_number": "815-933-8760",
            "fax_number": "815-933-9061"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KAZMIERCZAK",
        "first_name": "JEFFREY",
        "middle_name": "DAVID",
        "name_prefix": "Dr.",
        "credential": "PSY.D",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-02-04",
        "last_updated": "2012-04-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071008293",
            "primary": false
        },
        {
            "code": "103TA0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Adult Development & Aging",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC2200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "",
            "desc": "Psychologist, Counseling",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TR0400X",
            "taxonomy_group": "",
            "desc": "Psychologist, Rehabilitation",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TF0200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Forensic",
            "state": "IL",
            "license": "071008293",
            "primary": false
        },
        {
            "code": "103G00000X",
            "taxonomy_group": "",
            "desc": "Clinical Neuropsychologist",
            "state": "IL",
            "license": "071008293",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Neuropsychologist in Bourbonnais, IL
• Providers in Bourbonnais, IL by specialty
• Clinical Neuropsychologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.