Provider Demographics
NPI:1568261501
Name:WEST, JEREMIAH DALE I (CHW0000000623)
Entity type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:DALE
Last Name:WEST
Suffix:I
Gender:
Credentials:CHW0000000623
Other - Prefix:MR
Other - First Name:JEREMIAH
Other - Middle Name:DALE
Other - Last Name:BLOEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CHW
Mailing Address - Street 1:1450 S COOPER RD APT 1035
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-0301
Mailing Address - Country:US
Mailing Address - Phone:480-408-2694
Mailing Address - Fax:
Practice Address - Street 1:1940 E THUNDERBIRD RD STE 206
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5761
Practice Address - Country:US
Practice Address - Phone:480-408-2694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCHW0000000623172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker