Provider Demographics
NPI:1598052136
Name:WELCH, JERIMIE JAY (LMT)
Entity Type:Individual
Prefix:MR
First Name:JERIMIE
Middle Name:JAY
Last Name:WELCH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 W ROSCOE ST
Mailing Address - Street 2:3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2309
Mailing Address - Country:US
Mailing Address - Phone:312-612-9355
Mailing Address - Fax:
Practice Address - Street 1:928 W ROSCOE ST
Practice Address - Street 2:3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2309
Practice Address - Country:US
Practice Address - Phone:312-612-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-04
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227013022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist