Provider Demographics
NPI:1407001035
Name:EARL, JEREMY W (PT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:W
Last Name:EARL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5716
Mailing Address - Country:US
Mailing Address - Phone:315-725-1152
Mailing Address - Fax:315-798-4004
Practice Address - Street 1:1601 ARMORY DR
Practice Address - Street 2:BUILDING A
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5405
Practice Address - Country:US
Practice Address - Phone:315-798-4006
Practice Address - Fax:315-798-4004
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021116-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist