Provider Demographics
NPI:1487369948
Name:WHITE, JEREMY L
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:WHITE
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 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6235
Mailing Address - Country:US
Mailing Address - Phone:505-330-8220
Mailing Address - Fax:505-234-7867
Practice Address - Street 1:114 N BEHREND AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8414
Practice Address - Country:US
Practice Address - Phone:505-330-8220
Practice Address - Fax:505-234-7867
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst