Provider Demographics
NPI:1053447037
Name:ZAK, JED DEAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JED
Middle Name:DEAN
Last Name:ZAK
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 1:26 N HILL DR W
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-8147
Mailing Address - Country:US
Mailing Address - Phone:601-749-5976
Mailing Address - Fax:
Practice Address - Street 1:801 GOODYEAR BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3221
Practice Address - Country:US
Practice Address - Phone:601-798-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR867178367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS336508YYGZOtherMEDICARE
MS01689315Medicaid