Healthcare Provider Details

I. General information

NPI: 1982928065
Provider Name (Legal Business Name): JACK L. CROUGHAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD SUITE 970
SAINT LOUIS MO
63117-1223
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD SUITE 970
SAINT LOUIS MO
63117-1223
US

V. Phone/Fax

Practice location:
  • Phone: 314-725-4004
  • Fax: 314-725-4004
Mailing address:
  • Phone: 314-725-4004
  • Fax: 314-725-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberR5543
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR5543
License Number StateMO

VIII. Authorized Official

Name: MR. JACK LESTER CROUGHAN
Title or Position: PRESIDENT
Credential: MD
Phone: 314-725-4004