MEDICARE: JACOB AZERRAD PH.D.

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	101YM0800X	Mental Health Counselor	915	MA

General Provider Information

NPI Number	:	1922185479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB AZERRAD PH.D.

Provider Business Mailing Address
First Line	:	19 MUZZEY ST
Second Line	:	P.O. BOX 353, SUITE 310
City	:	LEXINGTON
State	:	MA
Zip	:	02421-5256
Country	:	US
Telephone Number	:	781-861-8637
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 MUZZEY ST
Second Line	:	SUITE 310
City	:	LEXINGTON
State	:	MA
Zip	:	02421-5256
Country	:	US
Telephone Number	:	781-861-8637
Fax Number	:

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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