Provider Demographics
NPI:1548932262
Name:FOSSUM, JEREMY (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FOSSUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FARM CREEK RD APT 245
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-9067
Mailing Address - Country:US
Mailing Address - Phone:402-957-7243
Mailing Address - Fax:
Practice Address - Street 1:512 N SHADY LN
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2991
Practice Address - Country:US
Practice Address - Phone:334-699-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist