Provider Demographics
NPI:1639573165
Name:KEGLEY, JACK (PC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KEGLEY
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 MEADOW DR STE A
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338-1389
Mailing Address - Country:US
Mailing Address - Phone:419-947-4560
Mailing Address - Fax:419-947-2956
Practice Address - Street 1:950 MEADOW DR STE A
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-1389
Practice Address - Country:US
Practice Address - Phone:419-947-4560
Practice Address - Fax:419-947-2956
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-6351101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health