Provider Demographics
NPI:1518094846
Name:THAYER, JEREMY (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:THAYER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 GARDINER RD
Mailing Address - Street 2:
Mailing Address - City:WEST KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02892-1068
Mailing Address - Country:US
Mailing Address - Phone:401-829-3355
Mailing Address - Fax:401-667-2733
Practice Address - Street 1:426 SCRABBLETOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-2001
Practice Address - Country:US
Practice Address - Phone:401-829-3355
Practice Address - Fax:401-667-2733
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW019341041C0700X
RICSW00983104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJT59949Medicaid