Provider Demographics
NPI:1104876044
Name:KLEIN, JEFFREY MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MARK
Last Name:KLEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 BOSLEY AVE
Mailing Address - Street 2:STE C3
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4399
Mailing Address - Country:US
Mailing Address - Phone:410-296-7422
Mailing Address - Fax:410-494-6637
Practice Address - Street 1:222 BOSLEY AVE
Practice Address - Street 2:STE C3
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4399
Practice Address - Country:US
Practice Address - Phone:410-296-7422
Practice Address - Fax:410-494-6637
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1180103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD300QMedicare PIN