Provider Demographics
NPI:1396895546
Name:GILLETTE, JEREMIAH LEE
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:LEE
Last Name:GILLETTE
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 1:322 CAHALEN ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43731-1302
Mailing Address - Country:US
Mailing Address - Phone:740-982-3229
Mailing Address - Fax:740-982-3229
Practice Address - Street 1:322 CAHALEN ST
Practice Address - Street 2:
Practice Address - City:CROOKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43731-1302
Practice Address - Country:US
Practice Address - Phone:740-982-3229
Practice Address - Fax:740-982-3229
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2359942Medicaid