Healthcare Provider Details

I. General information

NPI: 1851759211
Provider Name (Legal Business Name): JACK WHEELER DSW, MSW, LISW-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 1/2 BROADWAY E
GRANVILLE OH
43023-1304
US

IV. Provider business mailing address

120 1/2 BROADWAY E
GRANVILLE OH
43023-1304
US

V. Phone/Fax

Practice location:
  • Phone: 740-202-9938
  • Fax:
Mailing address:
  • Phone: 740-202-9938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1100212
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: