1205161064 NPI number — JEREMIAH RAY TITSWORTH MT-BC, LPMT

Table of content: JEREMIAH RAY TITSWORTH MT-BC, LPMT (NPI 1205161064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205161064 NPI number — JEREMIAH RAY TITSWORTH MT-BC, LPMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TITSWORTH
Provider First Name:
JEREMIAH
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MT-BC, LPMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEVENSON-TITSWORTH
Provider Other First Name:
JEREMIAH
Provider Other Middle Name:
RAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MT-BC, LPMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1205161064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2912 LAKESIDE DRIVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-605-9464
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2912 LAKESIDE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-605-9464
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225A00000X , with the licence number:  66 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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