Provider Demographics
NPI:1972010387
Name:FLETCHER, JEREMY RYAN (SSP, NCSP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1374
Mailing Address - Country:US
Mailing Address - Phone:618-282-6251
Mailing Address - Fax:618-282-6880
Practice Address - Street 1:1525 LOCUST ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1374
Practice Address - Country:US
Practice Address - Phone:618-282-6251
Practice Address - Fax:618-282-6880
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1903393103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool