Provider Demographics
NPI:1851030126
Name:PHAN, JEREMY (MS)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 S MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9391
Mailing Address - Country:US
Mailing Address - Phone:919-671-6438
Mailing Address - Fax:
Practice Address - Street 1:2006 S MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-9391
Practice Address - Country:US
Practice Address - Phone:919-671-6438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC17961101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health