Healthcare Provider Details

I. General information

NPI: 1881664449
Provider Name (Legal Business Name): JACK HENRY SCHNELLER JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W EUCLID AVE
DELAND FL
32720-6553
US

IV. Provider business mailing address

2259 S SPRING GARDEN AVE
DELAND FL
32720-4472
US

V. Phone/Fax

Practice location:
  • Phone: 386-943-9040
  • Fax: 386-943-9937
Mailing address:
  • Phone: 386-747-1351
  • Fax: 386-943-9937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS833
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: