Provider Demographics
NPI:1114352630
Name:JACK, TIFFANY (HIS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N COMMONS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7940
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:1130 BICHARA BLVD
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-7716
Practice Address - Country:US
Practice Address - Phone:352-750-4327
Practice Address - Fax:352-750-2410
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4900237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist