Provider Demographics
NPI:1306223359
Name:EAGLE, JOHN JR (LMSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EAGLE
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3283 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9511
Mailing Address - Country:US
Mailing Address - Phone:269-673-6617
Mailing Address - Fax:
Practice Address - Street 1:3283 122ND AVE.
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010
Practice Address - Country:US
Practice Address - Phone:269-673-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802082302104100000X
MI68011161171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker