Provider Demographics
NPI:1881664449
Name:SCHNELLER, JACK HENRY JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HENRY
Last Name:SCHNELLER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2259 S SPRING GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-4472
Mailing Address - Country:US
Mailing Address - Phone:386-747-1351
Mailing Address - Fax:386-943-9937
Practice Address - Street 1:1109 W EUCLID AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-6553
Practice Address - Country:US
Practice Address - Phone:386-943-9040
Practice Address - Fax:386-943-9937
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS833103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool