Provider Demographics
NPI:1518434646
Name:JEREMIAH, TRAVIS SCOTT
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:SCOTT
Last Name:JEREMIAH
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 1:318 S 174TH PL APT L
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1672
Mailing Address - Country:US
Mailing Address - Phone:206-841-8096
Mailing Address - Fax:
Practice Address - Street 1:2600 SW HOLDEN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3505
Practice Address - Country:US
Practice Address - Phone:206-933-7299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1518434646171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator