Provider Demographics
NPI: | 1356844849 |
---|---|
Name: | WEST, JEREMY (LICDC, LSW) |
Entity Type: | Individual |
Prefix: | |
First Name: | JEREMY |
Middle Name: | |
Last Name: | WEST |
Suffix: | |
Gender: | M |
Credentials: | LICDC, LSW |
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 3095 |
Mailing Address - Street 2: | |
Mailing Address - City: | DUBLIN |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43016-0046 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 517 3RD AVE |
Practice Address - Street 2: | |
Practice Address - City: | CHESAPEAKE |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45619-1036 |
Practice Address - Country: | US |
Practice Address - Phone: | 740-451-1455 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2018-03-12 |
Last Update Date: | 2024-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | S.2106970 | 104100000X |
171M00000X | ||
OH | LICDC.162185 | 101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0282128 | Medicaid |