Provider Demographics
NPI:1336433085
Name:CROTHERS, JACOB EMERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EMERSON
Last Name:CROTHERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 SAINT JOHN ST STE 322
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3059
Mailing Address - Country:US
Mailing Address - Phone:207-560-3422
Mailing Address - Fax:
Practice Address - Street 1:222 SAINT JOHN ST STE 322
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3059
Practice Address - Country:US
Practice Address - Phone:207-560-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT052724207Q00000X, 207QA0401X
MEMD208862083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400163444OtherMEDICARE FOR CROTHERS
CT008052299OtherMEDICAID FOR CROTHERS
CT004217099OtherMEDICAID PCS AT LONG WHARF
CT008052299OtherMEDICAID FOR CROTHERS