Provider Demographics
NPI:1063529162
Name:DAVIS, JACK MATHEW (FNP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MATHEW
Last Name:DAVIS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3523 TRAILWAY PARK ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDCOM
Practice Address - Street 2:ATTN: DCCS-QM (CREDENTIALS)
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-0054
Practice Address - Country:KR
Practice Address - Phone:0118227-916-6027
Practice Address - Fax:0118227-917-8110
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN073330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily