Provider Demographics
NPI:1861027625
Name:VANDEHURST, JEREMY SCOTT (L-AT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SCOTT
Last Name:VANDEHURST
Suffix:
Gender:M
Credentials:L-AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 SPRINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-2815
Mailing Address - Country:US
Mailing Address - Phone:530-208-8253
Mailing Address - Fax:
Practice Address - Street 1:2170 SOUTH AVE # B
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7008
Practice Address - Country:US
Practice Address - Phone:530-208-8253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0506428174H00000X, 207XX0005X, 208100000X, 226300000X, 405300000X, 207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No174H00000XOther Service ProvidersHealth Educator
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
No405300000XOther Service ProvidersPrevention Professional