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Individual

MR. JACKSON FAYETTE MCCULLOUGH JR.

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
B.S.

Contact information

Practice address
1732 ATKINSON ST, NEW CASTLE, PA 16101-1302
(724) 730-3414
Mailing address
1732 ATKINSON ST, NEW CASTLE, PA 16101-1302
(724) 730-3414

Taxonomy

Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SL001608L
PA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
19311180003
PA
Enumeration date
06/21/2007
Last updated
07/09/2007
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