Provider Demographics
NPI:1598362014
Name:KREKULA, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:KREKULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:ERWIN DANIE
Other - Last Name:KREKULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LADC
Mailing Address - Street 1:102 MAIN ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:STEWARTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55976-2608
Mailing Address - Country:US
Mailing Address - Phone:507-218-7114
Mailing Address - Fax:
Practice Address - Street 1:102 MAIN ST N STE 100
Practice Address - Street 2:
Practice Address - City:STEWARTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55976-2608
Practice Address - Country:US
Practice Address - Phone:507-218-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304745101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN304745OtherMINNESOTA BOARD OF BEHAVIOAL HEALTH