Provider Demographics
NPI:1922545789
Name:PRYOR, JEREMY EDWIN
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:EDWIN
Last Name:PRYOR
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 1:1534 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-2543
Mailing Address - Country:US
Mailing Address - Phone:469-491-8825
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3815
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator