Provider Demographics
NPI:1952494270
Name:SIDES, JERI KROGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERI
Middle Name:KROGH
Last Name:SIDES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3912
Mailing Address - Country:US
Mailing Address - Phone:207-773-4003
Mailing Address - Fax:
Practice Address - Street 1:30 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3912
Practice Address - Country:US
Practice Address - Phone:207-773-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPSY596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM3601Medicare ID - Type UnspecifiedMEDICARE NUMBER