Basic Information
| Provider Information | |||||||||
| NPI: | 1821240565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTTOMS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17273 STATE ROUTE 104 | ||||||||
| Address2: | CHILLICOTHE VAMC | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17273 STATE ROUTE 104 | ||||||||
| Address2: | CHILLICOTHE VAMC | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS016391 | PA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.