1811105216 NPI number — JEREMIAH M WRIGHT M.A., L.M.F.T.

Table of content: JEREMIAH M WRIGHT M.A., L.M.F.T. (NPI 1811105216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811105216 NPI number — JEREMIAH M WRIGHT M.A., L.M.F.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
JEREMIAH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., L.M.F.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811105216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 E JEFFERSON BLVD STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46601-1995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-383-5859
Provider Business Mailing Address Fax Number:
855-387-0446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 E JEFFERSON BLVD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1995
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-383-5859
Provider Business Practice Location Address Fax Number:
855-387-0446
Provider Enumeration Date:
05/18/2007

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: 106H00000X , with the licence number:  35001570A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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