Provider Demographics
NPI:1629840095
Name:HACKER, JEREMY DAVID
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:HACKER
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 1:519 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3933
Mailing Address - Country:US
Mailing Address - Phone:740-876-4370
Mailing Address - Fax:740-529-1818
Practice Address - Street 1:519 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3933
Practice Address - Country:US
Practice Address - Phone:740-876-4370
Practice Address - Fax:740-529-1818
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach