Provider Demographics
NPI:1568285583
Name:CECIL, JACK DEWAYNE JR (CRNP)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:DEWAYNE
Last Name:CECIL
Suffix:JR
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-2308
Mailing Address - Country:US
Mailing Address - Phone:724-322-1939
Mailing Address - Fax:
Practice Address - Street 1:728 BROAD AVE
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-1513
Practice Address - Country:US
Practice Address - Phone:724-929-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP031244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily