Healthcare Provider Details

I. General information

NPI: 1871047639
Provider Name (Legal Business Name): ANDREW JEREMIAH DAVIDSON STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

6232 MISSISSIPPI ST
CAMP LEJEUNE NC
28547-2532
US

V. Phone/Fax

Practice location:
  • Phone: 214-668-9607
  • Fax:
Mailing address:
  • Phone: 214-668-9607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number23588888
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number23588888
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: