Provider Demographics
NPI:1861224354
Name:MEDINA, JERAMIAH IVAN
Entity type:Individual
Prefix:
First Name:JERAMIAH
Middle Name:IVAN
Last Name:MEDINA
Suffix:
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 1:10054 MEADOWRUN DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-2878
Mailing Address - Country:US
Mailing Address - Phone:813-407-7275
Mailing Address - Fax:
Practice Address - Street 1:213 N PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4513
Practice Address - Country:US
Practice Address - Phone:813-407-7275
Practice Address - Fax:813-521-7415
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician