Provider Demographics
NPI:1427350651
Name:VINCENT, JEREMY C (MA, PLPC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:C
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 S WAVERLY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2497
Mailing Address - Country:US
Mailing Address - Phone:417-866-8262
Mailing Address - Fax:417-886-8109
Practice Address - Street 1:2053 S WAVERLY AVE STE D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2497
Practice Address - Country:US
Practice Address - Phone:417-866-8262
Practice Address - Fax:417-886-8109
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010039182101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor