Provider Demographics
NPI:1669868006
Name:CHAMBERLAIN, JUDE (PHD)
Entity type:Individual
Prefix:
First Name:JUDE
Middle Name:
Last Name:CHAMBERLAIN
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 1:6509 MARSOL RD
Mailing Address - Street 2:APT 526
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3571
Mailing Address - Country:US
Mailing Address - Phone:216-509-3003
Mailing Address - Fax:
Practice Address - Street 1:8701 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6103
Practice Address - Country:US
Practice Address - Phone:440-266-0770
Practice Address - Fax:440-266-0257
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7289103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7289OtherLICENSE NUMBER