Provider Demographics
NPI:1801803218
Name:JACK, RICHARD M (LCSW-R)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:JACK
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:102 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-4004
Practice Address - Country:US
Practice Address - Phone:518-585-6708
Practice Address - Fax:518-585-3260
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0608551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03201392Medicaid
NYR26898Medicare UPIN
NY03201392Medicaid