Healthcare Provider Details

I. General information

NPI: 1619084852
Provider Name (Legal Business Name): JAY SHUCK LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 FREDERICA ST
OWENSBORO KY
42301-5442
US

IV. Provider business mailing address

PO BOX 1429
MT WASHINGTON KY
40047-1429
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-2484
  • Fax:
Mailing address:
  • Phone: 877-992-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1062N
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: