Healthcare Provider Details

I. General information

NPI: 1588663033
Provider Name (Legal Business Name): JACK ROBERT MCDERMOTT D.C., FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4439 STATE ROUTE 159 STE 280
CHILLICOTHEE OH
45601-7502
US

IV. Provider business mailing address

4439 STATE ROUTE 159 STE 280
CHILLICOTHEE OH
45601-7502
US

V. Phone/Fax

Practice location:
  • Phone: 740-779-7050
  • Fax:
Mailing address:
  • Phone: 740-779-7050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14318
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3416
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4768
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number971
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: