Healthcare Provider Details

I. General information

NPI: 1396658456
Provider Name (Legal Business Name): JEREMIAH DAVISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S ELLIOTT AVE
AURORA MO
65605-2103
US

IV. Provider business mailing address

1401 S ELLIOTT AVE
AURORA MO
65605-2103
US

V. Phone/Fax

Practice location:
  • Phone: 417-986-9827
  • Fax:
Mailing address:
  • Phone: 417-671-9856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2026046825
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: