Healthcare Provider Details

I. General information

NPI: 1639573165
Provider Name (Legal Business Name): JACK KEGLEY PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 MEADOW DR STE A
MOUNT GILEAD OH
43338-1389
US

IV. Provider business mailing address

950 MEADOW DR STE A
MOUNT GILEAD OH
43338-1389
US

V. Phone/Fax

Practice location:
  • Phone: 419-947-4560
  • Fax: 419-947-2956
Mailing address:
  • Phone: 419-947-4560
  • Fax: 419-947-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC-6351
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: