Provider Demographics
NPI:1326670001
Name:PREWETT, JEREMY KYLE
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:KYLE
Last Name:PREWETT
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 1:10717 CAMINO RUIZ STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2364
Mailing Address - Country:US
Mailing Address - Phone:858-695-2211
Mailing Address - Fax:
Practice Address - Street 1:3702 RUFFIN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1893
Practice Address - Country:US
Practice Address - Phone:619-279-4300
Practice Address - Fax:619-297-4400
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA25-439207106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator