Provider Demographics
NPI:1205027612
Name:JEWELL, GEORGE R (PHD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:JEWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 BURNET AVE
Mailing Address - Street 2:3 SOUTH CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:513-585-5503
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:151 W GALBRAITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45216-1015
Practice Address - Country:US
Practice Address - Phone:513-418-4725
Practice Address - Fax:513-418-2618
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6364103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJECP3291Medicare PIN