Provider Demographics
NPI:1053797613
Name:MILLER, JEREMY KEITH (MSW, LISW-S,LICDC-CS)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:KEITH
Last Name:MILLER
Suffix:
Gender:M
Credentials:MSW, LISW-S,LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 DULTON DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-5109
Mailing Address - Country:US
Mailing Address - Phone:567-218-1980
Mailing Address - Fax:
Practice Address - Street 1:3401 GLENDALE AVE STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2490
Practice Address - Country:US
Practice Address - Phone:567-742-7117
Practice Address - Fax:567-200-8410
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700237-SUPV1041C0700X
OHLICDC.161437101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0231357Medicaid