Healthcare Provider Details

I. General information

NPI: 1043397474
Provider Name (Legal Business Name): JEREMY SEAN MCKAY PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17273 STATE ROUTE 104
CHILLICOTHEE OH
45601-9718
US

IV. Provider business mailing address

516 RIDLEY AVE
LAGRANGE GA
30240-2234
US

V. Phone/Fax

Practice location:
  • Phone: 740-773-1141
  • Fax:
Mailing address:
  • Phone: 706-845-1601
  • Fax: 706-845-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002848
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: