Provider Demographics
NPI:1285820084
Name:RIESENFELD, JEREMY JONATHAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JONATHAN
Last Name:RIESENFELD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 CALLE DE SEBASTIAN UNIT D1
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7321
Mailing Address - Country:US
Mailing Address - Phone:202-843-0790
Mailing Address - Fax:
Practice Address - Street 1:1810 CALLE DE SEBASTIAN UNIT D1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7321
Practice Address - Country:US
Practice Address - Phone:202-843-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCAC500095171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist