Provider Demographics
NPI:1609530070
Name:SEARLE, JEREMY KEITH
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEITH
Last Name:SEARLE
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 1:5290 S COBBLE CREEK RD APT 13C
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6742
Mailing Address - Country:US
Mailing Address - Phone:907-888-8993
Mailing Address - Fax:
Practice Address - Street 1:10 MOUNTAIN VIEW DR., EUREKA, MT 59917
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917
Practice Address - Country:US
Practice Address - Phone:406-297-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PTA-17113225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant