Provider Demographics
NPI:1104159623
Name:DAVALOZ, JEREMY
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:DAVALOZ
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:DAVALOZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS
Mailing Address - Street 1:211- B WAYNE ST.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4526
Mailing Address - Country:US
Mailing Address - Phone:931-560-3082
Mailing Address - Fax:931-560-3072
Practice Address - Street 1:211-B WAYNE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4526
Practice Address - Country:US
Practice Address - Phone:931-560-3082
Practice Address - Fax:931-560-3072
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator