Basic Information
| Provider Information | |||||||||
| NPI: | 1851910822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | JEREMIAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MULLINS DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973553983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412590235 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MERCY CIR | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035682525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2020 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 171000000X | Y | Other Service Providers | Military Health Care Provider |
No ID Information.