Provider Demographics
NPI:1194590067
Name:JACK, TRISHA NICOLE (HIS)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:NICOLE
Last Name:JACK
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:NICOLE
Other - Last Name:PERINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HIS
Mailing Address - Street 1:195 BOUNDRY LN
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-2992
Mailing Address - Country:US
Mailing Address - Phone:724-775-4327
Mailing Address - Fax:
Practice Address - Street 1:195 BOUNDRY LN
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-2992
Practice Address - Country:US
Practice Address - Phone:724-775-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF03919237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist