Provider Demographics
NPI:1982104402
Name:STEVENS, JEREMY SCOTT
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14749 DUSTI RD
Mailing Address - Street 2:
Mailing Address - City:EUSTACE
Mailing Address - State:TX
Mailing Address - Zip Code:75124-5543
Mailing Address - Country:US
Mailing Address - Phone:972-467-4465
Mailing Address - Fax:
Practice Address - Street 1:14749 DUSTI RD
Practice Address - Street 2:
Practice Address - City:EUSTACE
Practice Address - State:TX
Practice Address - Zip Code:75124-5543
Practice Address - Country:US
Practice Address - Phone:972-467-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX866747163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse