Provider Demographics
NPI:1841179835
Name:MCDERMOTT, IAN JAY
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:JAY
Last Name:MCDERMOTT
Suffix:
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 1:12945 W HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9107
Mailing Address - Country:US
Mailing Address - Phone:812-818-2518
Mailing Address - Fax:
Practice Address - Street 1:12945 W HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9107
Practice Address - Country:US
Practice Address - Phone:812-818-2518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY301310106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist