Provider Demographics
NPI:1811100845
Name:JEREMY, BRENT ALAN (LCSW)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
Last Name:JEREMY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 W 1ST SQ SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-2253
Mailing Address - Country:US
Mailing Address - Phone:772-562-4852
Mailing Address - Fax:
Practice Address - Street 1:2525 20TH ST.
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3026
Practice Address - Country:US
Practice Address - Phone:772-567-6508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 44451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAH367ZOtherPTAN