=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811105216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMIAH M WRIGHT M.A., L.M.F.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 04/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 E JEFFERSON BLVD STE 310
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-383-5859
-----------------------------------------------------
Fax | 855-387-0446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 E JEFFERSON BLVD STE 310
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-383-5859
-----------------------------------------------------
Fax | 855-387-0446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 35001570A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------