Provider Demographics
NPI:1346373750
Name:MARSHALL, JEFFREY TONKINS (MA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:TONKINS
Last Name:MARSHALL
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 1:5749 RUTH DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-2231
Mailing Address - Country:US
Mailing Address - Phone:704-763-0687
Mailing Address - Fax:
Practice Address - Street 1:5749 RUTH DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-2231
Practice Address - Country:US
Practice Address - Phone:704-763-0687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1663103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107028Medicaid