Provider Demographics
NPI:1205463924
Name:FACKELMAN, JEREMY DAVID (MS STUDENT COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DAVID
Last Name:FACKELMAN
Suffix:
Gender:M
Credentials:MS STUDENT COUNSELOR
Other - Prefix:
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Mailing Address - Street 1:7400 BLANCO RD STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4368
Mailing Address - Country:US
Mailing Address - Phone:210-446-8255
Mailing Address - Fax:210-437-4774
Practice Address - Street 1:7400 BLANCO RD STE 250
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4368
Practice Address - Country:US
Practice Address - Phone:210-446-8255
Practice Address - Fax:210-437-4774
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program