Provider Demographics
NPI:1124462734
Name:EDWARDS, JEREMIAH (LPT)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S GAREY AVE SPC 61
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5260
Mailing Address - Country:US
Mailing Address - Phone:909-272-7989
Mailing Address - Fax:
Practice Address - Street 1:3881 S WESTERN AVE
Practice Address - Street 2:2500 WILSHIRE BLVD SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-1105
Practice Address - Country:US
Practice Address - Phone:213-639-0251
Practice Address - Fax:213-389-7358
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36785167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician