Provider Demographics
NPI:1689418337
Name:WHEATLEY, JEREMY TODD
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
Last Name:WHEATLEY
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 1:121 MAN O WAR DR
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-7507
Mailing Address - Country:US
Mailing Address - Phone:859-297-8394
Mailing Address - Fax:
Practice Address - Street 1:106 BELINDA BLVD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-3217
Practice Address - Country:US
Practice Address - Phone:859-439-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist