Provider Demographics
NPI:1962168955
Name:ANDERSON, JEREMY EARLE
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:EARLE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S CHERRY ST APT 473
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CO
Mailing Address - Zip Code:80246-2755
Mailing Address - Country:US
Mailing Address - Phone:440-317-3779
Mailing Address - Fax:
Practice Address - Street 1:90 MADISON ST STE 704
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5416
Practice Address - Country:US
Practice Address - Phone:440-317-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker