Provider Demographics
NPI:1275240848
Name:ROGER, JEREMY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:ROGER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W ROLLING HILLS CIR APT 309
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1956
Mailing Address - Country:US
Mailing Address - Phone:484-892-5183
Mailing Address - Fax:
Practice Address - Street 1:220 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2416
Practice Address - Country:US
Practice Address - Phone:415-457-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist