Provider Demographics
NPI:1245314426
Name:KOWALSKI, JEROME J (MA)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:J
Last Name:KOWALSKI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5474 HIDDEN PINES DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-7765
Mailing Address - Country:US
Mailing Address - Phone:810-225-5604
Mailing Address - Fax:
Practice Address - Street 1:2300 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 180
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7367
Practice Address - Country:US
Practice Address - Phone:810-220-2787
Practice Address - Fax:810-220-2834
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007787103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist