Provider Demographics
NPI:1710084272
Name:CROWELL, JEREMY J
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:J
Last Name:CROWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2016
Mailing Address - Country:US
Mailing Address - Phone:571-214-4392
Mailing Address - Fax:
Practice Address - Street 1:625 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2917
Practice Address - Country:US
Practice Address - Phone:501-664-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC49836224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009190490Medicaid
DC034088300Medicaid
MD365350100Medicaid