Provider Demographics
NPI:1043747983
Name:MCCULLOUGH, JEREMY L (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60930
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:15331 CREATIVITY DR # 960
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701
Practice Address - Country:US
Practice Address - Phone:840-317-0888
Practice Address - Fax:540-739-7475
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17168225100000X
VA2305211812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist