Provider Demographics
NPI:1316286578
Name:OLDHAM, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:OLDHAM
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 1:688 E WATSON ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-2106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 PENNKNOLL RD
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-6940
Practice Address - Country:US
Practice Address - Phone:814-623-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000994225200000X
MDA2867225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant