Provider Demographics
NPI:1306472535
Name:HOGAN, JACK S JR
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:S
Last Name:HOGAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3029
Mailing Address - Country:US
Mailing Address - Phone:843-269-6737
Mailing Address - Fax:843-281-0126
Practice Address - Street 1:773 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3029
Practice Address - Country:US
Practice Address - Phone:843-269-6737
Practice Address - Fax:843-281-0126
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44172278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care