MEDICARE: MR. JACK A BEHR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		OH

General Provider Information

NPI Number	:	1437867520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK A BEHR

Provider Business Mailing Address
First Line	:	530 FOREST PARK CT APT E
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-1208
Country	:	US
Telephone Number	:	765-491-6390
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 FOREST PARK CT APT E
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-1208
Country	:	US
Telephone Number	:	765-491-6390
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2022
Last Update Date	:	11/08/2022

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