Provider Demographics
NPI:1073834214
Name:SQUIRES, JENNIFER CRUTCHFIELD (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CRUTCHFIELD
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1000
Mailing Address - Fax:704-384-1012
Practice Address - Street 1:2630 E 7TH ST STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4319
Practice Address - Country:US
Practice Address - Phone:704-384-1000
Practice Address - Fax:704-384-1012
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01668208000000X
GA4240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1073834214Medicaid