Provider Demographics
NPI:1750445409
Name:RUBIN, JEROME P (MED, MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:P
Last Name:RUBIN
Suffix:
Gender:M
Credentials:MED, MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MAIN ST
Mailing Address - Street 2:SUITE 213
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1584
Mailing Address - Country:US
Mailing Address - Phone:508-277-8770
Mailing Address - Fax:508-429-1242
Practice Address - Street 1:165 MAIN ST
Practice Address - Street 2:SUITE 213
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1584
Practice Address - Country:US
Practice Address - Phone:508-277-8770
Practice Address - Fax:508-429-1242
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10207441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA732532OtherTUFTS HEALTH PLAN ID
MA1012260OtherBEACON HEALTH STRAT ID
MA116026000OtherMAGELLAN BEHAVL HEALTH ID
MA1892592Medicaid
MA1892592Medicaid