Provider Demographics
NPI:1821729898
Name:CLEMONS, JEREMY DION
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DION
Last Name:CLEMONS
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 1:914 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3122
Mailing Address - Country:US
Mailing Address - Phone:281-917-6150
Mailing Address - Fax:
Practice Address - Street 1:914 N 27TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3122
Practice Address - Country:US
Practice Address - Phone:281-917-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDCLE-80-0414172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver