Provider Demographics
NPI:1689568578
Name:TAYLOR, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 N LUNA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6524
Mailing Address - Country:US
Mailing Address - Phone:773-633-4466
Mailing Address - Fax:
Practice Address - Street 1:534 WALLACE RD
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50011-4008
Practice Address - Country:US
Practice Address - Phone:515-294-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer