Provider Demographics
NPI:1922418565
Name:JEWELL, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:JEWELL
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 1:25 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:RI
Mailing Address - Zip Code:02885-3206
Mailing Address - Country:US
Mailing Address - Phone:401-247-0173
Mailing Address - Fax:
Practice Address - Street 1:25 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-3206
Practice Address - Country:US
Practice Address - Phone:401-247-0173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)