Provider Demographics
NPI:1255190807
Name:HARVILLE, JEREMY (ATC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:HARVILLE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-6316
Mailing Address - Country:US
Mailing Address - Phone:337-794-9314
Mailing Address - Fax:
Practice Address - Street 1:221 WARRIOR DR
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2726
Practice Address - Country:US
Practice Address - Phone:337-794-9314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT-06172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer