Provider Demographics
NPI:1659155679
Name:LECROY, JACK DILLARD
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DILLARD
Last Name:LECROY
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 1:297 VERA RD
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-4615
Mailing Address - Country:US
Mailing Address - Phone:912-314-5522
Mailing Address - Fax:
Practice Address - Street 1:11935 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1918
Practice Address - Country:US
Practice Address - Phone:912-478-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer