Provider Demographics
NPI:1891956561
Name:VAN WERT, JEREMY CLARK (MS MFTI)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:CLARK
Last Name:VAN WERT
Suffix:
Gender:M
Credentials:MS MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 ZINNIA WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6760
Mailing Address - Country:US
Mailing Address - Phone:916-521-7318
Mailing Address - Fax:
Practice Address - Street 1:1451 ZINNIA WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6760
Practice Address - Country:US
Practice Address - Phone:916-521-7318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist