Provider Demographics
NPI:1508696691
Name:FISHER, JEREMIAH (RADT-I)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7232 CANBY AVE STE 456
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3006
Mailing Address - Country:US
Mailing Address - Phone:818-705-5561
Mailing Address - Fax:
Practice Address - Street 1:7232 CANBY AVE STE 4.56
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3006
Practice Address - Country:US
Practice Address - Phone:818-705-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1564070624101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty