Provider Demographics
NPI:1033475678
Name:HARVEY, JACK ANDREW (DPM)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ANDREW
Last Name:HARVEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E NORTH ST
Mailing Address - Street 2:STE 106
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4961
Mailing Address - Country:US
Mailing Address - Phone:209-823-2700
Mailing Address - Fax:
Practice Address - Street 1:1234 E NORTH ST
Practice Address - Street 2:STE 106
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4961
Practice Address - Country:US
Practice Address - Phone:209-823-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAE5204213ES0103X
CAE-5204213EP1101X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist