Provider Demographics
NPI:1275390882
Name:MORENO, JEREMY QUERUEL
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:QUERUEL
Last Name:MORENO
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 1:19755 MOUNTAIN MDW N
Mailing Address - Street 2:
Mailing Address - City:HIDDEN VALLEY LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95467-8544
Mailing Address - Country:US
Mailing Address - Phone:714-925-0528
Mailing Address - Fax:
Practice Address - Street 1:1510 ARGONAUT RD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9361
Practice Address - Country:US
Practice Address - Phone:707-263-5819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator