Healthcare Provider Details

I. General information

NPI: 1295736288
Provider Name (Legal Business Name): JACK DARBYSHIRE ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23-25 BAYSTATE COURT
BREWSTER MA
02631-2556
US

IV. Provider business mailing address

164 CRANVIEW RD
BREWSTER MA
02631-2256
US

V. Phone/Fax

Practice location:
  • Phone: 508-240-7964
  • Fax: 508-240-5448
Mailing address:
  • Phone: 508-240-7964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4808
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: