Provider Demographics
NPI:1174553028
Name:PAWELECK-BELLINGRODT, JENNIFER KAYE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KAYE
Last Name:PAWELECK-BELLINGRODT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3973 N EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3672
Mailing Address - Country:US
Mailing Address - Phone:520-249-7007
Mailing Address - Fax:
Practice Address - Street 1:14539 W INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 800
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9279
Practice Address - Country:US
Practice Address - Phone:623-882-3364
Practice Address - Fax:623-882-3367
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ124025OtherMEDICARE PTAN
AZZ124025OtherMEDICARE PTAN