Provider Demographics
NPI:1073995312
Name:STEVENS, JEREMY DAVID (MS, LAT, ATC, OTC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MS, LAT, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 SCHOOL DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17026-9229
Mailing Address - Country:US
Mailing Address - Phone:717-376-7518
Mailing Address - Fax:
Practice Address - Street 1:345 SCHOOL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:PA
Practice Address - Zip Code:17026
Practice Address - Country:US
Practice Address - Phone:717-376-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0068502255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer