Healthcare Provider Details

I. General information

NPI: 1114357514
Provider Name (Legal Business Name): JEREMY KESTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 EBER RD
HOLLAND OH
43528-9616
US

IV. Provider business mailing address

1525 EBER RD
HOLLAND OH
43528-9697
US

V. Phone/Fax

Practice location:
  • Phone: 419-866-6500
  • Fax:
Mailing address:
  • Phone: 419-866-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07988
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: