Provider Demographics
NPI:1245409788
Name:EGAN, JEREM ST JOHN (LMT)
Entity Type:Individual
Prefix:MR
First Name:JEREM
Middle Name:ST JOHN
Last Name:EGAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 N CENTRAL AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5900
Mailing Address - Country:US
Mailing Address - Phone:541-282-7950
Mailing Address - Fax:541-857-4531
Practice Address - Street 1:33 N CENTRAL AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5900
Practice Address - Country:US
Practice Address - Phone:541-282-7950
Practice Address - Fax:541-857-4531
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist