Provider Demographics
NPI:1174261853
Name:FISK, JEREMIAH DARION (MED, LPC)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:DARION
Last Name:FISK
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 E WASHINGTON AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-5705
Mailing Address - Country:US
Mailing Address - Phone:956-517-9766
Mailing Address - Fax:
Practice Address - Street 1:1902 E WASHINGTON AVE APT 33
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-5705
Practice Address - Country:US
Practice Address - Phone:956-517-9766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83720101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional