Healthcare Provider Details

I. General information

NPI: 1346860434
Provider Name (Legal Business Name): JACQUELINE M CRAWFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NEWTON RD
IOWA CITY IA
52242
US

IV. Provider business mailing address

1738 LININGER LN STE A
NORTH LIBERTY IA
52317-2316
US

V. Phone/Fax

Practice location:
  • Phone: 319-335-7440
  • Fax: 319-335-7442
Mailing address:
  • Phone: 319-252-1435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS-09982
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES-30582
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: