Provider Demographics
NPI:1588663033
Name:MCDERMOTT, JACK ROBERT (DC, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ROBERT
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:DC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4439 STATE ROUTE 159 STE 280
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7502
Mailing Address - Country:US
Mailing Address - Phone:740-779-7050
Mailing Address - Fax:
Practice Address - Street 1:4439 STATE ROUTE 159 STE 280
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7502
Practice Address - Country:US
Practice Address - Phone:740-779-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3416111N00000X
KY4768111N00000X
WV971111N00000X
OH14318363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA.14318-NPOtherSTATE OF OHIO LICENSE