1811424070 NPI number — DR. JEREMY BRADLEY JACOX MD, PHD

Table of content: DR. JEREMY BRADLEY JACOX MD, PHD (NPI 1811424070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811424070 NPI number — DR. JEREMY BRADLEY JACOX MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOX
Provider First Name:
JEREMY
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811424070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 CEDAR ST
Provider Second Line Business Mailing Address:
WWW205
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06510-3206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-785-4095
Provider Business Mailing Address Fax Number:
203-785-4116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-407-8038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  1.076512 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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