Healthcare Provider Details

I. General information

NPI: 1336032408
Provider Name (Legal Business Name): JERAMIE ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 3RD AVE
ROCK ISLAND IL
61201-8840
US

IV. Provider business mailing address

2911 6TH AVE
ROCK ISLAND IL
61201-1914
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-2094
  • Fax:
Mailing address:
  • Phone: 563-506-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131651
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: