Provider Demographics
NPI:1114681830
Name:DILLER, JEREMY JAMES
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
Last Name:DILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 POND RUN RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:STOUT
Mailing Address - State:OH
Mailing Address - Zip Code:45684-9104
Mailing Address - Country:US
Mailing Address - Phone:740-357-8810
Mailing Address - Fax:
Practice Address - Street 1:14574 ST RT 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690
Practice Address - Country:US
Practice Address - Phone:740-912-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health