Healthcare Provider Details

I. General information

NPI: 1689908436
Provider Name (Legal Business Name): JEREMY DANIEL BARTZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CASIA VA MEDICAL CENTER (116B)
SAN JUAN PR
00921-3201
US

IV. Provider business mailing address

3936 ADMIRABLE DR
RANCHO PALOS VERDES CA
90275-6028
US

V. Phone/Fax

Practice location:
  • Phone: 801-318-2439
  • Fax:
Mailing address:
  • Phone: 801-318-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: