MEDICARE: JHEREMY PETE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1225708654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JHEREMY PETE

Provider Business Mailing Address
First Line	:	1718 N 77TH GLN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-5053
Country	:	US
Telephone Number	:	623-337-0256
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 N 77TH GLN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-5053
Country	:	US
Telephone Number	:	623-337-0256
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2021
Last Update Date	:	10/01/2021

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Directions to “ JHEREMY PETE ” Practice Location

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