Provider Demographics
NPI:1427815034
Name:JACK, DANE
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:JACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5738
Mailing Address - Country:US
Mailing Address - Phone:352-434-5158
Mailing Address - Fax:
Practice Address - Street 1:1450 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5738
Practice Address - Country:US
Practice Address - Phone:352-434-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker