| Organization Name: | JACK L. CROUGHAN INC |
| NPI Number: | 1982928065 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JACK LESTER CROUGHAN (PRESIDENT) |
| Mailing Address: | 1034 S Brentwood Blvd Suite 970 Saint Louis |
| State: | MO US |
| Postal Code: | 631171223 |
| Phone Number: | 3147254004 |
| Fax Number: | 3147254004 |
| NPI Enumeration Date: | 03/18/2010 |
| NPI Last Update Date: | 03/18/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2084A0401X |
| License Number: | R5543 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Psychiatry & Neurology |
| Taxonomy Specialization: | Addiction Medicine |
| Taxonomy Definition: | A doctor of osteopathy board eligible/certified in the field of Psychiatry by the American Osteopathic Board of Neurology and Psychiatry is able to obtain a Certificate of Added Qualifications in the field of Addiction Medicine |