Provider Demographics
NPI:1063517068
Name:JACK, JAMES E (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:E
Last Name:JACK
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 1:2745 E OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1635
Mailing Address - Country:US
Mailing Address - Phone:954-630-1616
Mailing Address - Fax:954-656-1365
Practice Address - Street 1:2745 E OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1635
Practice Address - Country:US
Practice Address - Phone:954-630-1616
Practice Address - Fax:954-656-1365
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8419111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU66946Medicare UPIN
FL89576ZMedicare ID - Type Unspecified