Provider Demographics
NPI:1538221445
Name:FOUGHTY, JACK B (DC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:B
Last Name:FOUGHTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6822 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7336
Mailing Address - Country:US
Mailing Address - Phone:330-499-0147
Mailing Address - Fax:330-499-8148
Practice Address - Street 1:6822 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7336
Practice Address - Country:US
Practice Address - Phone:330-499-0147
Practice Address - Fax:330-499-8148
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0525168Medicaid
OHF0490552Medicare ID - Type Unspecified
OH0525168Medicaid