Provider Demographics
NPI:1346860434
Name:CRAWFORD, JACQUELINE M
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 LININGER LN STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-2316
Mailing Address - Country:US
Mailing Address - Phone:319-252-1435
Mailing Address - Fax:
Practice Address - Street 1:801 NEWTON RD
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-335-7440
Practice Address - Fax:319-335-7442
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IARES-30582390200000X
IADDS-099821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program