Provider Demographics
NPI:1144455619
Name:ZACKERY, JOHN WESLEY II
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WESLEY
Last Name:ZACKERY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 1/2 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-2267
Mailing Address - Country:US
Mailing Address - Phone:620-474-2205
Mailing Address - Fax:620-664-5158
Practice Address - Street 1:700 1/2 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-2267
Practice Address - Country:US
Practice Address - Phone:620-474-2205
Practice Address - Fax:620-664-5158
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS251B000000XMedicaid