Provider Demographics
NPI:1922887165
Name:MOTA, JERAMIE JASON
Entity Type:Individual
Prefix:MR
First Name:JERAMIE
Middle Name:JASON
Last Name:MOTA
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 1:672 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1540
Mailing Address - Country:US
Mailing Address - Phone:203-996-2558
Mailing Address - Fax:
Practice Address - Street 1:55 CHARTER OAK DR
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-1050
Practice Address - Country:US
Practice Address - Phone:203-996-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT209109538172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver