MEDICARE: JACK CROWLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		NY

General Provider Information

NPI Number	:	1124960463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK CROWLEY

Provider Business Mailing Address
First Line	:	19 MORNINGSIDE PARK
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14607-3015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 WASHINGTON ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-4034
Country	:	US
Telephone Number	:	315-779-5244
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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Directions to “ JACK CROWLEY ” Practice Location

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