Provider Demographics
NPI:1619388907
Name:REDFEARN, JEREMY (ATP)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:REDFEARN
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-2083
Mailing Address - Country:US
Mailing Address - Phone:903-575-1305
Mailing Address - Fax:903-572-1301
Practice Address - Street 1:1432 W 16TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2083
Practice Address - Country:US
Practice Address - Phone:903-575-1305
Practice Address - Fax:903-572-1301
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010549601Medicaid
TX010549603Medicaid
TX010549602Medicaid
TX016383402Medicaid
TX079392902Medicaid
TX079392902Medicaid