Provider Demographics
NPI:1649811902
Name:KING, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KING
Suffix:
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 1:810 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PROCTOR
Mailing Address - State:MN
Mailing Address - Zip Code:55810-2705
Mailing Address - Country:US
Mailing Address - Phone:218-341-5513
Mailing Address - Fax:
Practice Address - Street 1:2501 RICE LAKE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4819
Practice Address - Country:US
Practice Address - Phone:218-625-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7926235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty