Gregory Bruce Jack, LPC
Individual provider Active NPI Professional Counselor · Plainfield, CT
NPI 1164517512 · NPPES record last updated Nov 14, 2024
Key facts
- NPI
- 1164517512
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Professional Counselor 101YP2500X
- License
- 000758 (CT)
- Practice address
- 50 Academy Hill Road
Plainfield, CT 06374 - Phone
- (860) 564-3015
- Fax
- (860) 564-3025
- NPI assigned
- Oct 3, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 6
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Mental Health Counselor
- Education
- Other, 1977
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Day Kimball Healthcare, Inc.
Practice addresses (Care Compare)
320 Pomfret St
Putnam, CT 06260-1836
Phone (860) 928-6541
Hospital & facility affiliations
- Day Kimball Hospital
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CT
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240212004009 | CT | Practitioner - Mental Health Counselor | 1355784844 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 000758 | CT | MD | Professional Counselor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Day Kimball Healthcare, Inc. | Current |
Accepting new patients | |
| Day Kimball Healthcare, Inc. | Current | Accepting new patients | |
| University Pathologists, LLC | Current | Accepting new patients | |
| Day Kimball Healthcare, Inc. | Current |
Accepting new patients |
Locations
320 Pomfret St
Putnam, CT 06260
Phone (860) 963-6331
Interoperability endpoints
- gregory.jack.1@29658.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 000758 | CT | Yes |
Addresses
Primary practice location
50 Academy Hill Road
Plainfield, CT 06374
Mailing address
50 Academy Hill Road, P.O. Box 201
Plainfield, CT 06374
Phone (860) 564-3015
Other providers in Plainfield, CT
- Helping Hands Transportation LLC
- Susan Honeychurch
- Heather Hunnicutt
- Alexis Jamie Hutchings
- Honeylet Alonte Ibia
- Sunit Jain
- Patricia Diana Kaliszewski
- Adithi Karthikeyan
- Caroline Koshis
- Sherry Lee Kroll
All providers in Plainfield, CT · Professional Counselor in Connecticut
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 14, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.