Provider Demographics
NPI:1376162180
Name:UTTER, JEREMY M
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:UTTER
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 1:1749 EATON RD APT 25
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-8314
Mailing Address - Country:US
Mailing Address - Phone:530-514-9859
Mailing Address - Fax:
Practice Address - Street 1:590 RIO LINDO AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1817
Practice Address - Country:US
Practice Address - Phone:530-345-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-11
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328141164W00000X
CA709453164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse