Basic Information
| Provider Information | |||||||||
| NPI: | 1710454541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEERHEIM | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 N IRON BRIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992024932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2018 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60420761 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | LW60899726 | WA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.