Provider Demographics
NPI:1699048975
Name:CRUMBLISS, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CRUMBLISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3713 UNIVERSITY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6202
Mailing Address - Country:US
Mailing Address - Phone:917-859-0456
Mailing Address - Fax:
Practice Address - Street 1:3713 UNIVERSITY DR
Practice Address - Street 2:SUITE A
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6202
Practice Address - Country:US
Practice Address - Phone:917-859-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2013-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical