Provider Demographics
NPI:1134493620
Name:JACK, ASHLEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:L
Last Name:JACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 VALENCIA CIR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-1339
Mailing Address - Country:US
Mailing Address - Phone:303-931-8976
Mailing Address - Fax:
Practice Address - Street 1:655 SEVENTH STREET, BLDG 700
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31028
Practice Address - Country:US
Practice Address - Phone:303-931-8976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant