Provider Demographics
NPI:1750862819
Name:FAY, JACKSON RICHARD (LSW, BSW)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:RICHARD
Last Name:FAY
Suffix:
Gender:M
Credentials:LSW, BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-697-8010
Mailing Address - Fax:
Practice Address - Street 1:1624 TIFFIN AVE STE A
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-6852
Practice Address - Country:US
Practice Address - Phone:419-427-3320
Practice Address - Fax:419-427-1697
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904009104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty