Provider Demographics
NPI:1043028236
Name:JERZYKOWSKI, ASHLEY (LSW, RBT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JERZYKOWSKI
Suffix:
Gender:F
Credentials:LSW, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5776 GRAPE RD.
Mailing Address - Street 2:PMB 171
Mailing Address - City:MISHWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545
Mailing Address - Country:US
Mailing Address - Phone:574-217-1624
Mailing Address - Fax:
Practice Address - Street 1:4609 GRAPE RD STE D1B
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-8259
Practice Address - Country:US
Practice Address - Phone:574-217-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33010569A104100000X
INRBT-22-136513106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker