Provider Demographics
NPI:1265247993
Name:WALLIS, JEREME
Entity type:Individual
Prefix:MR
First Name:JEREME
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 N 54TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-3029
Mailing Address - Country:US
Mailing Address - Phone:402-613-6430
Mailing Address - Fax:
Practice Address - Street 1:1935 N 54TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-3029
Practice Address - Country:US
Practice Address - Phone:402-613-6430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion