Provider Demographics
NPI:1013461953
Name:HART, JEREMY RYAN (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:RYAN
Last Name:HART
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-2103
Mailing Address - Country:US
Mailing Address - Phone:870-273-5454
Mailing Address - Fax:
Practice Address - Street 1:1607 STONE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5332
Practice Address - Country:US
Practice Address - Phone:870-932-5551
Practice Address - Fax:870-932-5552
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist