| Doctor Name: | MR. JACK WEAVER |
| NPI Number: | 1184055048 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | ALC |
| License Number: | C2207A |
| Business Practice Address: | 521 Gault Ave N Fort Payne, AL - 359672307 |
| Business Phone Number: | 2562737216 |
| Business Fax Number: | |
| Mailing Address: | 521 Gault Ave N, FORT PAYNE |
| State: | AL |
| Postal Code: | 359672307 |
| Phone Number: | 2562737216 |
| Fax Number: | |
| NPI Enumeration Date: | 12/03/2013 |
| NPI Last Update Date: | 12/03/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | C2207A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |