Provider Demographics
NPI:1154409480
Name:HARLOW, JEFFREY (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HARLOW
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:PO BOX 4009
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4009
Mailing Address - Country:US
Mailing Address - Phone:304-348-1288
Mailing Address - Fax:304-348-1262
Practice Address - Street 1:1418 A MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303
Practice Address - Country:US
Practice Address - Phone:304-348-1288
Practice Address - Fax:304-348-1262
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV344103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164868000Medicaid
WVCP10522Medicare PIN