Provider Demographics
NPI:1437867520
Name:BEHR, JACK A
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:A
Last Name:BEHR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 FOREST PARK CT APT E
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-1208
Mailing Address - Country:US
Mailing Address - Phone:765-491-6390
Mailing Address - Fax:
Practice Address - Street 1:530 FOREST PARK CT APT E
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1208
Practice Address - Country:US
Practice Address - Phone:765-491-6390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program