Provider Demographics
NPI:1962423384
Name:MACEY, JACK (CRNA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MACEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-0428
Mailing Address - Country:US
Mailing Address - Phone:570-386-2366
Mailing Address - Fax:570-386-3130
Practice Address - Street 1:1501 MOUNT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:VILLANOVA
Practice Address - State:PA
Practice Address - Zip Code:19085-2112
Practice Address - Country:US
Practice Address - Phone:670-527-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN22868L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA008456PSSMedicare ID - Type Unspecified