Provider Demographics
NPI:1104948041
Name:TIPS, JACK C (PHD, CCN)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:TIPS
Suffix:
Gender:M
Credentials:PHD, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9419 PRINCE WILLIAM
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-328-3996
Mailing Address - Fax:512-263-7787
Practice Address - Street 1:9419 WESTMINSTER GLEN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78730
Practice Address - Country:US
Practice Address - Phone:512-328-3996
Practice Address - Fax:512-263-7787
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0017161133NN1002X, 136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered