Provider Demographics
NPI:1467202945
Name:WARDER, JACK RICHARD
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:RICHARD
Last Name:WARDER
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 1:1565 BEAR CREEK LN UNIT M
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8371
Mailing Address - Country:US
Mailing Address - Phone:307-433-4655
Mailing Address - Fax:
Practice Address - Street 1:347 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8676
Practice Address - Country:US
Practice Address - Phone:231-487-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist