Provider Demographics
NPI:1952820482
Name:WATERS, JACK (LCDC-III, QMHS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:LCDC-III, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4431 MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8890
Mailing Address - Country:US
Mailing Address - Phone:740-703-5507
Mailing Address - Fax:
Practice Address - Street 1:15221 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661
Practice Address - Country:US
Practice Address - Phone:740-493-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)