Provider Demographics
NPI:1831954726
Name:VINCENT, JEREMIAH (BA)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:VINCENT
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 W KALAMAZOO AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3347
Mailing Address - Country:US
Mailing Address - Phone:269-598-0925
Mailing Address - Fax:
Practice Address - Street 1:440 W KALAMAZOO AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3347
Practice Address - Country:US
Practice Address - Phone:269-598-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker