Provider Demographics
NPI:1992289417
Name:HACKLEY, JERRY RYAN III (MSW, LSW)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:RYAN
Last Name:HACKLEY
Suffix:III
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44273-8864
Mailing Address - Country:US
Mailing Address - Phone:330-591-4648
Mailing Address - Fax:
Practice Address - Street 1:269 CENTER ST
Practice Address - Street 2:
Practice Address - City:SEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44273-8864
Practice Address - Country:US
Practice Address - Phone:330-591-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1903598104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker