Provider Demographics
NPI:1609198241
Name:ANDERSON, JEREMY C (MFTA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 CR 90 STE 215
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-5111
Mailing Address - Country:US
Mailing Address - Phone:281-412-6863
Mailing Address - Fax:281-412-3940
Practice Address - Street 1:2225 CR 90 STE 215
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-5111
Practice Address - Country:US
Practice Address - Phone:281-412-6863
Practice Address - Fax:281-412-3940
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201205106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist