1588663033 NPI number — DR. JACK ROBERT MCDERMOTT D.C., FNP-BC

Table of content: DR. JACK ROBERT MCDERMOTT D.C., FNP-BC (NPI 1588663033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588663033 NPI number — DR. JACK ROBERT MCDERMOTT D.C., FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDERMOTT
Provider First Name:
JACK
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C., FNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588663033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4439 STATE ROUTE 159 STE 280
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILLICOTHE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45601-7502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-779-7050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4439 STATE ROUTE 159 STE 280
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILLICOTHE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45601-7502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-779-7050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3416 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 4768 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 971 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 14318 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: COA.14318-NP . This is a "STATE OF OHIO LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".