Provider Demographics
NPI:1265604185
Name:SCHULTZ, JACK GORDON JR (MSP)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:GORDON
Last Name:SCHULTZ
Suffix:JR
Gender:M
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 INDIGO AVE
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-3210
Mailing Address - Country:US
Mailing Address - Phone:803-586-5280
Mailing Address - Fax:
Practice Address - Street 1:1006 INDIGO AVE
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3210
Practice Address - Country:US
Practice Address - Phone:803-586-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist