Healthcare Provider Details

I. General information

NPI: 1619943784
Provider Name (Legal Business Name): JACK A COLE PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S KITCHELL AVE
OLNEY IL
62450-1500
US

IV. Provider business mailing address

302 S. KITCHELL AVENUE
OLNEY IL
62450
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-6261
  • Fax:
Mailing address:
  • Phone: 618-395-6261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042023A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: