Provider Demographics
NPI:1215470125
Name:STEPHENSON, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:STEPHENSON
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 1:1451 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1718
Mailing Address - Country:US
Mailing Address - Phone:606-836-6683
Mailing Address - Fax:606-324-0616
Practice Address - Street 1:1451 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1718
Practice Address - Country:US
Practice Address - Phone:606-836-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-24
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004165225100000X
KY006678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist