Provider Demographics
NPI:1861526725
Name:CLEVEN, JEREMY L (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:CLEVEN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 NICOLET DR
Mailing Address - Street 2:UW-GREEN BAY
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7003
Mailing Address - Country:US
Mailing Address - Phone:920-465-2138
Mailing Address - Fax:920-465-2652
Practice Address - Street 1:2420 NICOLET DR
Practice Address - Street 2:UW-GREEN BAY
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7003
Practice Address - Country:US
Practice Address - Phone:920-465-2138
Practice Address - Fax:920-465-2652
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI644-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer