=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679982789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY KEITH SEVERIN COUNSELOR MENTAL H
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2014
-----------------------------------------------------
Last Update Date | 08/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 COHASSET RD STE 130
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95926-2283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-200-6561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2708 WHITE AVE APT 2
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-0491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-200-6561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------