Provider Demographics
NPI:1538832266
Name:AJETI, JEREMY (BS)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:AJETI
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:BITTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 ADDISON AVE W STE 1000
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5853
Mailing Address - Country:US
Mailing Address - Phone:208-736-5048
Mailing Address - Fax:208-735-2126
Practice Address - Street 1:630 ADDISON AVE W STE 1000
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5853
Practice Address - Country:US
Practice Address - Phone:208-736-5048
Practice Address - Fax:208-735-2126
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID2786392228OtherTREATMENT AND RECOVERY CENTER