Provider Demographics
NPI:1639151483
Name:CARLSON, JEREMY M (MSPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2779
Mailing Address - Country:US
Mailing Address - Phone:541-732-8280
Mailing Address - Fax:
Practice Address - Street 1:870 S FRONT ST
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2779
Practice Address - Country:US
Practice Address - Phone:541-732-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275342Medicaid
OR081009-026OtherBLUECROSS BLUESHIELD
ORR119235Medicare PIN