Basic Information
| Provider Information | |||||||||
| NPI: | 1750667226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTMAN | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2412 WARWICK AVE | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750284615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592735947 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1133 COLOMA WAY STE C | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167746647 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 203942 | TX | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | IMF# 66456 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.