Provider Demographics
NPI:1598385718
Name:MACK, JARVIS
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:
Last Name:MACK
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 1:2105 ASHLAND ST APT B
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-9032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2105 ASHLAND ST APT B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-9032
Practice Address - Country:US
Practice Address - Phone:330-356-2510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child