Healthcare Provider Details

I. General information

NPI: 1003685843
Provider Name (Legal Business Name): JEREMY HARRIS HOTTLE CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 W BROAD ST
COLUMBUS OH
43204-2653
US

IV. Provider business mailing address

3035 W BROAD ST
COLUMBUS OH
43204-2653
US

V. Phone/Fax

Practice location:
  • Phone: 614-272-7005
  • Fax: 614-272-7008
Mailing address:
  • Phone: 614-272-7005
  • Fax: 614-272-7008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number183691
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: