Provider Demographics
NPI:1790071389
Name:TAKAHASHI, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:TAKAHASHI
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 1:367 CEDAR ST # 421
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3222
Mailing Address - Country:US
Mailing Address - Phone:925-301-5005
Mailing Address - Fax:
Practice Address - Street 1:367 CEDAR ST # 421
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3222
Practice Address - Country:US
Practice Address - Phone:925-301-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTN/A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program