Provider Demographics
NPI:1659860740
Name:HAGGERTY, JACK O'NEILL (LPN)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:O'NEILL
Last Name:HAGGERTY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N MAIN ST APT B
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-2099
Mailing Address - Country:US
Mailing Address - Phone:740-358-3950
Mailing Address - Fax:
Practice Address - Street 1:304 N MAIN ST APT B
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-2099
Practice Address - Country:US
Practice Address - Phone:740-358-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN154443164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse