Provider Demographics
NPI:1083232524
Name:MUTTER, JEREMY COBB (RCP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:COBB
Last Name:MUTTER
Suffix:
Gender:M
Credentials:RCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 W BENJAMIN HOLT DR APT 14
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-3344
Mailing Address - Country:US
Mailing Address - Phone:916-397-9495
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-3806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22678227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified