Provider Demographics
NPI:1871549980
Name:JERRAM, MATTHEW WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:JERRAM
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 1:1679 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1807
Mailing Address - Country:US
Mailing Address - Phone:617-388-6876
Mailing Address - Fax:617-441-7510
Practice Address - Street 1:1679 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1807
Practice Address - Country:US
Practice Address - Phone:617-388-6876
Practice Address - Fax:617-441-7510
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06387OtherBLUE CROSS BLUE SHIELD MA
MAQ52707Medicare UPIN
MAJE-W51458Medicare ID - Type Unspecified