Provider Demographics
NPI:1235415746
Name:EVERETT, JEREMY CHAD (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:CHAD
Last Name:EVERETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CROWN POINTE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-1192
Mailing Address - Country:US
Mailing Address - Phone:817-757-1678
Mailing Address - Fax:817-757-1679
Practice Address - Street 1:101 CROWN POINTE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-1192
Practice Address - Country:US
Practice Address - Phone:817-757-1678
Practice Address - Fax:817-757-1679
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBT10036678207Q00000X
TXP7107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicare PIN