Healthcare Provider Details

I. General information

NPI: 1568393171
Provider Name (Legal Business Name): JACK O'HARA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 WILSON RD
EAST LANSING MI
48824-6410
US

IV. Provider business mailing address

313 N CEDAR ST APT 317
LANSING MI
48912-1290
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-9616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: