Provider Demographics
NPI:1902103773
Name:HURST, JEREMY JEROME (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JEROME
Last Name:HURST
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 OLD JACKS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-7716
Mailing Address - Country:US
Mailing Address - Phone:731-989-2303
Mailing Address - Fax:
Practice Address - Street 1:412 JUANITA DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-1949
Practice Address - Country:US
Practice Address - Phone:731-989-7598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000004581225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant