Basic Information
| Provider Information | |||||||||
| NPI: | 1215470125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHENSON | ||||||||
| FirstName: | JEREMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 GREENUP AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411011953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063240540 | ||||||||
| FaxNumber: | 6063240616 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GRANDVIEW DR | ||||||||
| Address2: | |||||||||
| City: | FLATWOODS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411391024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068363187 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2016 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004165 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 006678 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.