Provider Demographics
NPI:1033314760
Name:MCCULLOUGH, JACKSON FAYETTE JR (BS)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:FAYETTE
Last Name:MCCULLOUGH
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-1302
Mailing Address - Country:US
Mailing Address - Phone:724-730-3414
Mailing Address - Fax:
Practice Address - Street 1:1732 ATKINSON ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-1302
Practice Address - Country:US
Practice Address - Phone:724-730-3414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL001608L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA19311180003Medicaid