Healthcare Provider Details

I. General information

NPI: 1568054732
Provider Name (Legal Business Name): JEREMY MCCANN CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 3RD AVE
CHESAPEAKE OH
45619-1036
US

IV. Provider business mailing address

517 3RD AVE
CHESAPEAKE OH
45619-1036
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-0483
  • Fax:
Mailing address:
  • Phone: 740-451-0483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.178309
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.175915
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: