Provider Demographics
NPI:1003294562
Name:CROWE, JEFFERSON MARTIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:MARTIN
Last Name:CROWE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 HUMPHREY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2638
Mailing Address - Country:US
Mailing Address - Phone:303-304-6528
Mailing Address - Fax:
Practice Address - Street 1:8 FANEUIL HALL MARKETPLACE # 326
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-6114
Practice Address - Country:US
Practice Address - Phone:303-304-6528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10361103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750847844OtherNATIONAL PROVIDER IDENTIFIER TYPE 2