Provider Demographics
NPI:1033270848
Name:ENNIS, JEREMY S (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:S
Last Name:ENNIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:360-475-5115
Mailing Address - Fax:
Practice Address - Street 1:1 BOONE RD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1894
Practice Address - Country:US
Practice Address - Phone:360-315-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE688171000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider