Provider Demographics
NPI:1093731507
Name:JACK, MADELINE (MD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15W 72ND ST 4O
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3424
Mailing Address - Country:US
Mailing Address - Phone:212-579-8166
Mailing Address - Fax:212-579-8166
Practice Address - Street 1:15W 72ND ST 4O
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3424
Practice Address - Country:US
Practice Address - Phone:212-579-8166
Practice Address - Fax:212-579-8166
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-0492261104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker