Healthcare Provider Details

I. General information

NPI: 1447176508
Provider Name (Legal Business Name): JEREMY C TILLACK CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 OAK ST
MARION OH
43302-2906
US

IV. Provider business mailing address

152 OAK ST
MARION OH
43302-2906
US

V. Phone/Fax

Practice location:
  • Phone: 567-409-1989
  • Fax:
Mailing address:
  • Phone: 567-409-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number190323
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: