Provider Demographics
NPI:1023244852
Name:FOWLER, JEB THOMAS (PHD)
Entity type:Individual
Prefix:MR
First Name:JEB
Middle Name:THOMAS
Last Name:FOWLER
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 1:21 BARTLETT CRES # 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2208
Mailing Address - Country:US
Mailing Address - Phone:617-444-9513
Mailing Address - Fax:
Practice Address - Street 1:1 ARNOLD CIR STE 7
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-2250
Practice Address - Country:US
Practice Address - Phone:617-444-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10122103TP0814X, 103TC1900X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst