Provider Demographics
NPI:1316063308
Name:KYLE, JACK BRITTON JR (RN)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:BRITTON
Last Name:KYLE
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3713 24TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-2015
Mailing Address - Country:US
Mailing Address - Phone:217-853-2284
Mailing Address - Fax:
Practice Address - Street 1:3713 24TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-2015
Practice Address - Country:US
Practice Address - Phone:217-853-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583215163W00000X
TXAP108453367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119911906Medicaid
TX84894UOtherBCBS