Provider Demographics
NPI:1336472232
Name:BOONE, JEREMIAH RAY
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:RAY
Last Name:BOONE
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 1:1301 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3124
Mailing Address - Country:US
Mailing Address - Phone:714-317-9877
Mailing Address - Fax:
Practice Address - Street 1:901 W VICTORIA ST
Practice Address - Street 2:SUITE F & G
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-5807
Practice Address - Country:US
Practice Address - Phone:714-317-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW281941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical