Provider Demographics
NPI:1326335837
Name:WEINSTOCK, JEREMIAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:
Last Name:WEINSTOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 LACLEDE AVE
Mailing Address - Street 2:SHANNON HALL, ROOM 208
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2010
Mailing Address - Country:US
Mailing Address - Phone:314-977-2137
Mailing Address - Fax:
Practice Address - Street 1:3511 LACLEDE AVE
Practice Address - Street 2:SHANNON HALL, ROOM 208
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2010
Practice Address - Country:US
Practice Address - Phone:314-977-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010033592103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical