Healthcare Provider Details

I. General information

NPI: 1083232524
Provider Name (Legal Business Name): JEREMY COBB MUTTER RCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 01/03/2022
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

3790 W BENJAMIN HOLT DR APT 14
STOCKTON CA
95219-3344
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-3806
  • Fax:
Mailing address:
  • Phone: 916-397-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number22678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: