Provider Demographics
NPI:1205297801
Name:TAYLOR, JEREMY (ATC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:3833 STONE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7219
Mailing Address - Country:US
Mailing Address - Phone:231-590-0765
Mailing Address - Fax:
Practice Address - Street 1:3833 STONE RIDGE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7219
Practice Address - Country:US
Practice Address - Phone:231-590-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer