Provider Demographics
NPI:1649874926
Name:SIMMONS, JACK RICHARD
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:RICHARD
Last Name:SIMMONS
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 1:26067 WILLOWBEND RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9111
Mailing Address - Country:US
Mailing Address - Phone:740-814-7264
Mailing Address - Fax:
Practice Address - Street 1:26067 WILLOWBEND RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-9111
Practice Address - Country:US
Practice Address - Phone:740-814-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)