Provider Demographics
NPI:1518939057
Name:DICUS, JEREMY RAYMOND (AT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RAYMOND
Last Name:DICUS
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 SHERIDAN DR
Mailing Address - Street 2:APARTMENT H
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-1940
Mailing Address - Country:US
Mailing Address - Phone:740-821-2775
Mailing Address - Fax:
Practice Address - Street 1:OHIO UNIVERSITY
Practice Address - Street 2:GROVER CENTER E207
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2979
Practice Address - Country:US
Practice Address - Phone:740-593-9497
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0025542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer