Provider Demographics
NPI:1013445402
Name:JEWETT, RON ALLEN
Entity type:Individual
Prefix:
First Name:RON
Middle Name:ALLEN
Last Name:JEWETT
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 1:10 53RD ST UNIT 303
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-7228
Mailing Address - Country:US
Mailing Address - Phone:208-308-4578
Mailing Address - Fax:
Practice Address - Street 1:10514 RACETRACK RD STE G
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3241
Practice Address - Country:US
Practice Address - Phone:208-308-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1588102552Medicaid