Healthcare Provider Details

I. General information

NPI: 1023664976
Provider Name (Legal Business Name): MR. MATTHEW DAVID COY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 STATE ST
JACKSON OH
45640-1171
US

IV. Provider business mailing address

296 STATE ST
JACKSON OH
45640-1171
US

V. Phone/Fax

Practice location:
  • Phone: 220-710-1221
  • Fax:
Mailing address:
  • Phone: 220-710-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2303308
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: