Provider Demographics
NPI:1235267386
Name:VILTZ, JEROME TIMOTHY
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:TIMOTHY
Last Name:VILTZ
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 1:1014 CHRISTOPHER LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015-2823
Mailing Address - Country:US
Mailing Address - Phone:615-792-2836
Mailing Address - Fax:
Practice Address - Street 1:511 8TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3093
Practice Address - Country:US
Practice Address - Phone:931-920-7263
Practice Address - Fax:931-920-7202
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6865101YM0800X
1744R1102X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1744R1102XOther Service ProvidersSpecialistResearch Study