Healthcare Provider Details

I. General information

NPI: 1134697022
Provider Name (Legal Business Name): JEREMY DANIEL SEFFENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 NORTH DR
HOPKINSVILLE KY
42240-2620
US

IV. Provider business mailing address

PO BOX 614
HOPKINSVILLE KY
42241-0614
US

V. Phone/Fax

Practice location:
  • Phone: 270-886-5163
  • Fax: 270-886-5178
Mailing address:
  • Phone: 270-886-2205
  • Fax: 270-886-0392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number255669
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: