Provider Demographics
NPI:1396764692
Name:GAINES, JEFFREY JAY (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAY
Last Name:GAINES
Suffix:
Gender:M
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-0191
Mailing Address - Country:US
Mailing Address - Phone:617-223-1563
Mailing Address - Fax:
Practice Address - Street 1:50 ELM ST
Practice Address - Street 2:SUITE 6
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2574
Practice Address - Country:US
Practice Address - Phone:617-223-1563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8264103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAGA W51372Medicare ID - Type UnspecifiedMEDICARE B