Provider Demographics
NPI:1841374360
Name:EHMKE, JEREMY TODD (EDS, NCSP)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:TODD
Last Name:EHMKE
Suffix:
Gender:M
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19450 E REINS RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-8612
Mailing Address - Country:US
Mailing Address - Phone:480-987-0318
Mailing Address - Fax:
Practice Address - Street 1:20740 S ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-9058
Practice Address - Country:US
Practice Address - Phone:480-987-5900
Practice Address - Fax:480-987-9714
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3671793103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool