Provider Demographics
NPI: | 1508202268 |
---|---|
Name: | JEREMY W OWENS, MD, PC |
Entity Type: | Organization |
Organization Name: | JEREMY W OWENS, MD, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PHYSICIAN |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JEREMY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | OWENS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 228-331-3310 |
Mailing Address - Street 1: | 15190 COMMUNITY RD |
Mailing Address - Street 2: | SUITE 260 |
Mailing Address - City: | GULFPORT |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 39503-3485 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 15190 COMMUNITY RD |
Practice Address - Street 2: | SUITE 260 |
Practice Address - City: | GULFPORT |
Practice Address - State: | MS |
Practice Address - Zip Code: | 39503-3485 |
Practice Address - Country: | US |
Practice Address - Phone: | 228-331-3310 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-05-21 |
Last Update Date: | 2013-05-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | 20354 | 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Single Specialty |