Provider Demographics
NPI:1033314331
Name:JACK, MICHELE D (RN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:JACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17028 ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:SMETHPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16749-4024
Mailing Address - Country:US
Mailing Address - Phone:814-887-2229
Mailing Address - Fax:
Practice Address - Street 1:20 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1257
Practice Address - Country:US
Practice Address - Phone:814-362-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN524462L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse