Provider Demographics
NPI:1306878368
Name:POLCZINSKI, JEFFREY LEWIS (PSYD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEWIS
Last Name:POLCZINSKI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1641057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39131300Medicaid
WI1641057OtherPSCYHOLOGIST LICENSE
WI39131300Medicaid
88274Medicare ID - Type Unspecified