Active NPI
Richard M Jack, LCSW-R
- Clinical Social Worker
- Ticonderoga, NY
National Provider Identifier
1801803218
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 060855
- Practice address
- 102 Race Track Rd
Ticonderoga, NY 12883-4004 - Phone
- (518) 585-6708
- Fax
- (518) 585-3260
- NPI assigned
- Aug 1, 2006
- Last updated
- Feb 7, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 060855 | NY | Primary |
Addresses
Primary practice location
102 Race Track Rd
Ticonderoga, NY 12883-4004
Mailing address
9 Carey Rd
Queensbury, NY 12804-7880
Phone (518) 761-0300
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 03201392 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 060855 | NY | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Essex County Treasurer | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
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NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154390400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1486425600000",
"number": "1801803218",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9 CAREY RD",
"city": "QUEENSBURY",
"state": "NY",
"postal_code": "128047880",
"telephone_number": "518-761-0300",
"fax_number": "518-824-2388"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "102 RACE TRACK RD",
"city": "TICONDEROGA",
"state": "NY",
"postal_code": "128834004",
"telephone_number": "518-585-6708",
"fax_number": "518-585-3260"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACK",
"first_name": "RICHARD",
"middle_name": "M",
"credential": "LCSW-R",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-01",
"last_updated": "2017-02-07",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "NY",
"license": "060855",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "03201392",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Ticonderoga, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.