Provider Demographics
NPI:1851943138
Name:LANDRETH, JEREMY MICHAEL (CDC I)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:LANDRETH
Suffix:
Gender:M
Credentials:CDC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 TUDOR CENTRE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5912
Mailing Address - Country:US
Mailing Address - Phone:907-729-6351
Mailing Address - Fax:907-729-5180
Practice Address - Street 1:225 EAGLE ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-2626
Practice Address - Country:US
Practice Address - Phone:907-729-6550
Practice Address - Fax:907-278-6631
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health