Provider Demographics
NPI:1083104137
Name:JACK, NICOLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:JACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2500 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9774
Mailing Address - Country:US
Mailing Address - Phone:815-844-5343
Mailing Address - Fax:815-844-5715
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-844-5343
Practice Address - Fax:815-844-5715
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant