Provider Demographics
NPI:1346372778
Name:STEVENS, JACK H (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:H
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 781629
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1629
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:700 CHILDREN'S DRIVE J WEST 4TH FLOOR
Practice Address - Street 2:NATIONWIDE CHILDREN'S HOSPITAL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-4700
Practice Address - Fax:614-722-4718
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5848103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid