Provider Demographics
NPI:1154177285
Name:CHADWICK, JEREMY LEE (LMT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEE
Last Name:CHADWICK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3293 E FIRST ST
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-7152
Mailing Address - Country:US
Mailing Address - Phone:706-946-2017
Mailing Address - Fax:
Practice Address - Street 1:3293 E FIRST ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-7152
Practice Address - Country:US
Practice Address - Phone:706-946-2017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT014209225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist