Healthcare Provider Details

I. General information

NPI: 1932643830
Provider Name (Legal Business Name): JEREMY NELSON L.P.C.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 OLD TROY PIKE
DAYTON OH
45424-5740
US

IV. Provider business mailing address

4710 OLD TROY PIKE
DAYTON OH
45424-5740
US

V. Phone/Fax

Practice location:
  • Phone: 937-853-5449
  • Fax: 937-236-8930
Mailing address:
  • Phone: 937-853-5449
  • Fax: 937-236-8930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1200685
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: