Basic Information
| Provider Information | |||||||||
| NPI: | 1881931020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEDZWIECKI | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S., LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S SUNSET CANYON DR | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915011102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189703965 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14658 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914113119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187850703 | ||||||||
| FaxNumber: | 8187850145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2013 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 96393 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.