Provider Demographics
NPI:1811680408
Name:DAVIS, JEREMY RISHARD (ALC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:RISHARD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8254 COUNTY ROAD 64 UNIT 1003
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-8717
Mailing Address - Country:US
Mailing Address - Phone:251-300-9525
Mailing Address - Fax:
Practice Address - Street 1:224 1ST ST N STE 250
Practice Address - Street 2:
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-9071
Practice Address - Country:US
Practice Address - Phone:205-876-8512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health