Healthcare Provider Details

I. General information

NPI: 1629311915
Provider Name (Legal Business Name): JEREMY ANDREW COURTNEY M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 DOUBLE A RANCH RD.
ASH FORK AZ
86320
US

IV. Provider business mailing address

PO BOX 806
ASH FORK AZ
86320-0806
US

V. Phone/Fax

Practice location:
  • Phone: 928-707-2393
  • Fax:
Mailing address:
  • Phone: 928-707-2393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-11472
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: