Provider Demographics
NPI:1578852661
Name:JEDRZKIEWICZ, JOLANTA
Entity type:Individual
Prefix:
First Name:JOLANTA
Middle Name:
Last Name:JEDRZKIEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JAGIELLONSKA 239 ST
Mailing Address - Street 2:
Mailing Address - City:MILOWKA
Mailing Address - State:SLASK
Mailing Address - Zip Code:34360
Mailing Address - Country:PL
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:434 2ND AVE APT 4
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-5623
Practice Address - Country:US
Practice Address - Phone:203-848-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
UT8414833-1205207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program