Provider Demographics
NPI:1023533825
Name:BLASER, JEREMIAH (PT, DPT)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:BLASER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1686 HENRY LUCKOW LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1705
Mailing Address - Country:US
Mailing Address - Phone:815-547-4777
Mailing Address - Fax:815-547-1024
Practice Address - Street 1:1686 HENRY LUCKOW LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1705
Practice Address - Country:US
Practice Address - Phone:815-547-4777
Practice Address - Fax:815-547-1024
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.023017225100000X
KYCP027048T225100000X
MOCP027049T225100000X
VACP027051T225100000X
TNCP027050T225100000X
SCCP031411T225100000X
WI16127-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist