Healthcare Provider Details

I. General information

NPI: 1487137477
Provider Name (Legal Business Name): JEREMY JARVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S LAUREL RD STE 109
LONDON KY
40744-8304
US

IV. Provider business mailing address

103 OHIO LN
LONDON KY
40741-2026
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 606-657-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: