Basic Information
| Provider Information | |||||||||
| NPI: | 1689398075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOZEN | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TRAVIS | ||||||||
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| Credential: | PTA | ||||||||
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| OtherLastName: | KOZEN | ||||||||
| OtherFirstName: | J | ||||||||
| OtherMiddleName: | TRAVIS | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 407 MCKINLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253141038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045431196 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 TRACY WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047200205 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2022 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA000975 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.