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General NPI Number Information
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NPI Number | 1619084852
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Entity Type | Individual
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Provider Name | JAY SHUCK LPCA
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Gender | Male
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Dates
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Enumeration Date | 08/24/2006
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Last Update Date | 04/09/2013
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Provider Practice Location Address
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Address Line | 2720 FREDERICA ST
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City | OWENSBORO
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State | KY
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Zip | 42301-5442
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Country | US
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Telephone | 270-926-2484
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1429
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City | MT WASHINGTON
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State | KY
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Zip | 40047-1429
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Country | US
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Telephone | 877-992-5242
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1062N
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License Number State | KY
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