Healthcare Provider Details

I. General information

NPI: 1023244852
Provider Name (Legal Business Name): JEB THOMAS FOWLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ARNOLD CIR STE 7
CAMBRIDGE MA
02139-2250
US

IV. Provider business mailing address

21 BARTLETT CRES # 1
BROOKLINE MA
02446-2208
US

V. Phone/Fax

Practice location:
  • Phone: 617-444-9513
  • Fax:
Mailing address:
  • Phone: 617-444-9513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number10122
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number10122
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number10122
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: