Provider Demographics
NPI:1689398075
Name:KOZEN, JEREMY TRAVIS (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:TRAVIS
Last Name:KOZEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:J
Other - Middle Name:TRAVIS
Other - Last Name:KOZEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:407 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1038
Mailing Address - Country:US
Mailing Address - Phone:304-543-1196
Mailing Address - Fax:
Practice Address - Street 1:400 TRACY WAY STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1280
Practice Address - Country:US
Practice Address - Phone:304-720-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA000975225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant