Provider Demographics
NPI:1821273814
Name:HENSON, JERAMY PAUL (IDC)
Entity Type:Individual
Prefix:
First Name:JERAMY
Middle Name:PAUL
Last Name:HENSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 SENN RD STE 7
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5049
Mailing Address - Country:US
Mailing Address - Phone:619-556-5454
Mailing Address - Fax:619-556-3325
Practice Address - Street 1:3325 SENN RD STE 7
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5049
Practice Address - Country:US
Practice Address - Phone:619-556-5454
Practice Address - Fax:619-556-3325
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman