Provider Demographics
NPI:1679975783
Name:COLE, JEREMY (BCABA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PARKWAY
Mailing Address - Street 2:SUITE 903
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:921 CHARLIE SMITH SR. HIGHWAY
Practice Address - Street 2:
Practice Address - City:ST. MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558
Practice Address - Country:US
Practice Address - Phone:912-576-7070
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst