Provider Demographics
NPI:1275945305
Name:CREWS, JACQUELYN FARYN (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:FARYN
Last Name:CREWS
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 1:601 5TH ST S STE 504
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4804
Mailing Address - Country:US
Mailing Address - Phone:727-767-8917
Mailing Address - Fax:727-767-8482
Practice Address - Street 1:501 6TH AVE SOUTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-767-4106
Practice Address - Fax:727-767-8804
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL131145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020389300Medicaid
FL131145OtherMEDICAL LICENSE