Provider Demographics
NPI:1366047912
Name:ONEILL, JACK W (MS, AT, CES)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:W
Last Name:ONEILL
Suffix:
Gender:M
Credentials:MS, AT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 SEQUOIA AVE
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9031
Mailing Address - Country:US
Mailing Address - Phone:614-619-9920
Mailing Address - Fax:
Practice Address - Street 1:6955 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8580
Practice Address - Country:US
Practice Address - Phone:614-619-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0046442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAT004644OtherOT, PT, AT BOARD