Provider Demographics
NPI:1700200680
Name:STEPHENS, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:STEPHENS
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 1:801 OLD HARSHMAN RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 OLD HARSHMAN RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:OH
Practice Address - Zip Code:45431-1238
Practice Address - Country:US
Practice Address - Phone:937-259-6603
Practice Address - Fax:937-259-6611
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1155279103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool