Provider Demographics
NPI:1871009449
Name:VANDERPOOL, JEREMY D (COUNSELOR TRAINEE)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:VANDERPOOL
Suffix:
Gender:M
Credentials:COUNSELOR TRAINEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 COOK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9600
Mailing Address - Country:US
Mailing Address - Phone:513-228-7800
Mailing Address - Fax:513-725-2231
Practice Address - Street 1:50 GREENWOOD LN
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-3033
Practice Address - Country:US
Practice Address - Phone:937-746-1154
Practice Address - Fax:937-746-8523
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.151540101YA0400X
OHC.1901668-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)