Provider Demographics
NPI:1922312347
Name:CHACK, JONATHAN (MA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CHACK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EAST ST
Mailing Address - Street 2:
Mailing Address - City:AYER
Mailing Address - State:MA
Mailing Address - Zip Code:01432-1805
Mailing Address - Country:US
Mailing Address - Phone:978-464-1048
Mailing Address - Fax:
Practice Address - Street 1:10 EAST ST
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1805
Practice Address - Country:US
Practice Address - Phone:978-464-1048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health