Provider Demographics
NPI:1104999085
Name:BEINASHOWITZ, JACK (PHD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BEINASHOWITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5220
Mailing Address - Country:US
Mailing Address - Phone:617-441-8010
Mailing Address - Fax:
Practice Address - Street 1:1105 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5220
Practice Address - Country:US
Practice Address - Phone:617-441-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6765103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05349Medicare ID - Type Unspecified