Provider Demographics
NPI:1073134508
Name:CHAMBLISS, JEREMIAH HOSEA DENARD
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:HOSEA DENARD
Last Name:CHAMBLISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 7TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-2726
Mailing Address - Country:US
Mailing Address - Phone:727-637-2178
Mailing Address - Fax:
Practice Address - Street 1:112 POST OAK RD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-4967
Practice Address - Country:US
Practice Address - Phone:727-637-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16304225X00000X
VA0119009433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist