Provider Demographics
NPI:1205407228
Name:TODD, JEREMY JUSTIN
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JUSTIN
Last Name:TODD
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 1:400 ESTUDILLO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4962
Mailing Address - Country:US
Mailing Address - Phone:510-924-0548
Mailing Address - Fax:
Practice Address - Street 1:2050 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1001
Practice Address - Country:US
Practice Address - Phone:510-924-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA716058164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse