Provider Demographics
NPI:1497234850
Name:STEWART, JEREMY ROBERT (COTA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ROBERT
Last Name:STEWART
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 FLEMING ST
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-3049
Mailing Address - Country:US
Mailing Address - Phone:409-938-8282
Mailing Address - Fax:
Practice Address - Street 1:4905 FLEMING ST
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-3049
Practice Address - Country:US
Practice Address - Phone:409-938-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209407224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209407OtherTEXAS OTA LICENSE