Provider Demographics
NPI:1124291976
Name:JEFFREY L POLCZINSKI PSYD LLC
Entity type:Organization
Organization Name:JEFFREY L POLCZINSKI PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLCZINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-967-9550
Mailing Address - Street 1:5555 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-967-9550
Mailing Address - Fax:414-967-9550
Practice Address - Street 1:5555 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 304
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-967-9550
Practice Address - Fax:414-967-9550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1641057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39131300Medicaid
WI88274Medicare PIN