Provider Demographics
NPI:1962648394
Name:GARDNER, JEREMY DAVID (OT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:GARDNER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7502 QUAIL MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77071-2314
Mailing Address - Country:US
Mailing Address - Phone:845-641-0562
Mailing Address - Fax:
Practice Address - Street 1:7502 QUAIL MEADOW DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77071-2314
Practice Address - Country:US
Practice Address - Phone:845-641-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 002833171100000X
TX115501225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171100000XOther Service ProvidersAcupuncturist