Provider Demographics
NPI:1265483804
Name:SKELTON, JACK STEPHEN (LCSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:STEPHEN
Last Name:SKELTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:SKELTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0340
Practice Address - Street 1:240 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3988
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:765-741-0340
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001343A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN209610VMedicare ID - Type Unspecified