Provider Demographics
NPI:1104165224
Name:WYSOCKI, JACEK BERNARD (LMFT)
Entity type:Individual
Prefix:
First Name:JACEK
Middle Name:BERNARD
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:213-821-6500
Mailing Address - Fax:
Practice Address - Street 1:1031 W 34TH ST STE 500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-2501
Practice Address - Country:US
Practice Address - Phone:213-821-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT101799106H00000X
CAIMF 71895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist