Provider Demographics
NPI:1679394738
Name:MCDOUGAL, JAIDEN
Entity type:Individual
Prefix:
First Name:JAIDEN
Middle Name:
Last Name:MCDOUGAL
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 1:5150 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5150 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2441
Practice Address - Country:US
Practice Address - Phone:614-604-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician