Provider Demographics
NPI:1568899805
Name:PENROD, JEREMIAH L (SMFT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:L
Last Name:PENROD
Suffix:
Gender:M
Credentials:SMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 W VISTA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5918
Mailing Address - Country:US
Mailing Address - Phone:417-597-4309
Mailing Address - Fax:
Practice Address - Street 1:560 W MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-9681
Practice Address - Country:US
Practice Address - Phone:417-413-1593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist