Provider Demographics
NPI:1336981943
Name:PEVAHOUSE, JEREMY LUKE
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:LUKE
Last Name:PEVAHOUSE
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 1:95 MISTALA CT
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-3832
Mailing Address - Country:US
Mailing Address - Phone:304-283-9757
Mailing Address - Fax:
Practice Address - Street 1:73 EDMOND RD STE 2
Practice Address - Street 2:
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430-2793
Practice Address - Country:US
Practice Address - Phone:681-252-4685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002009225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant