Healthcare Provider Details

I. General information

NPI: 1902502230
Provider Name (Legal Business Name): JEREMIAH JOSEPH KUDISCH RMHCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7270 HILBURN RD APT 8
PENSACOLA FL
32504-6392
US

IV. Provider business mailing address

7270 HILBURN RD APT 8
PENSACOLA FL
32504-6392
US

V. Phone/Fax

Practice location:
  • Phone: 813-638-7582
  • Fax:
Mailing address:
  • Phone: 813-638-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH22943
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: