Provider Demographics
NPI:1760276216
Name:WHITE, JEREMIAH SR
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:WHITE
Suffix:SR
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 1:3340 GREENWAY DR
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-2642
Mailing Address - Country:US
Mailing Address - Phone:573-481-5473
Mailing Address - Fax:
Practice Address - Street 1:4615 DUNN AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-6512
Practice Address - Country:US
Practice Address - Phone:573-481-5473
Practice Address - Fax:573-481-5473
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion