Provider Demographics
NPI:1831347129
Name:FOUNTAIN, JACK III
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:FOUNTAIN
Suffix:III
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 1:2232 TIMES AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-2116
Mailing Address - Country:US
Mailing Address - Phone:330-412-7963
Mailing Address - Fax:
Practice Address - Street 1:2232 TIMES AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-2116
Practice Address - Country:US
Practice Address - Phone:330-412-7963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant