Provider Demographics
NPI:1588687230
Name:DUBOSE, JACK EDWARD (CRT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:EDWARD
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 HARGROVE DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5411
Mailing Address - Country:US
Mailing Address - Phone:228-872-1556
Mailing Address - Fax:
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified