Provider Demographics
NPI:1528309267
Name:HUGHES, JACK J III (COTA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:J
Last Name:HUGHES
Suffix:III
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4476 N 622 W
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-8984
Mailing Address - Country:US
Mailing Address - Phone:260-358-8827
Mailing Address - Fax:
Practice Address - Street 1:1850 W MATADOR ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3711
Practice Address - Country:US
Practice Address - Phone:765-689-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002213A313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility