Provider Demographics
NPI:1346465614
Name:FREEMAN, JEROME
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:FREEMAN
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 1:168 W WALNUT AVE APT D
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3412
Mailing Address - Country:US
Mailing Address - Phone:909-620-2521
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5407
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:909-620-9793
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259990164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse