Provider Demographics
NPI:1043787088
Name:BUCK, JACK WARREN JR
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WARREN
Last Name:BUCK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MCKINNEY TRL
Mailing Address - Street 2:
Mailing Address - City:FATE
Mailing Address - State:TX
Mailing Address - Zip Code:75087-9266
Mailing Address - Country:US
Mailing Address - Phone:214-558-8714
Mailing Address - Fax:
Practice Address - Street 1:206 MCKINNEY TRL
Practice Address - Street 2:
Practice Address - City:FATE
Practice Address - State:TX
Practice Address - Zip Code:75087-9266
Practice Address - Country:US
Practice Address - Phone:214-558-8714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX725113163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics