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General NPI Number Information
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NPI Number | 1336981943
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Entity Type | Individual
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Provider Name | JEREMY LUKE PEVAHOUSE
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Gender | Male
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Dates
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Enumeration Date | 06/12/2024
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Last Update Date | 06/12/2024
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Provider Practice Location Address
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Address Line | 73 EDMOND RD STE 2
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City | KEARNEYSVILLE
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State | WV
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Zip | 25430-2793
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Country | US
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Telephone | 681-252-4685
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Fax |
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Provider Business Mailing Address
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Address Line | 95 MISTALA CT
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City | INWOOD
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State | WV
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Zip | 25428-3832
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Country | US
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Telephone | 304-283-9757
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 002009
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License Number State | WV
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