Provider Demographics
NPI:1699345587
Name:SUTHERLAND, JEREMY SCOTT (BA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 BENONI AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-0045
Mailing Address - Country:US
Mailing Address - Phone:681-404-6135
Mailing Address - Fax:
Practice Address - Street 1:701 BENONI AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-0045
Practice Address - Country:US
Practice Address - Phone:681-404-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator