Provider Demographics
NPI:1851155766
Name:OLIVER, JACK JR
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:OLIVER
Suffix:JR
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 1:461 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:NEW PHILA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-2735
Mailing Address - Country:US
Mailing Address - Phone:330-205-2348
Mailing Address - Fax:
Practice Address - Street 1:461 3RD ST NE
Practice Address - Street 2:
Practice Address - City:NEW PHILA
Practice Address - State:OH
Practice Address - Zip Code:44663-2735
Practice Address - Country:US
Practice Address - Phone:330-205-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health