MEDICARE: JEREMY POLING LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0701007197	VA

General Provider Information

NPI Number	:	1962925818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY POLING LPC

Provider Business Mailing Address
First Line	:	5530 GLADEVIEW DR
Second Line	:
City	:	BRIDGEWATER
State	:	VA
Zip	:	22812-9701
Country	:	US
Telephone Number	:	540-830-1777
Fax Number	:	540-466-1770

Provider Business Practice Location Address
First Line	:	3617 BUTTERMILK CREEK RD
Second Line	:
City	:	ROCKINGHAM
State	:	VA
Zip	:	22802-1022
Country	:	US
Telephone Number	:	540-830-1777
Fax Number	:	540-466-1770

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2017
Last Update Date	:	03/17/2018

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