Provider Demographics
NPI:1063171064
Name:GLEASON, JEREMY FORREST
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:FORREST
Last Name:GLEASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 ALA MOANA BLVD APT 2517
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-1624
Mailing Address - Country:US
Mailing Address - Phone:361-362-8275
Mailing Address - Fax:
Practice Address - Street 1:45 WORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE PEARL HARBOR- HICKAM
Practice Address - State:HI
Practice Address - Zip Code:96853
Practice Address - Country:US
Practice Address - Phone:361-362-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic