Provider Demographics
NPI:1194017806
Name:DR. JONATHAN E JACK DC PLLC
Entity Type:Organization
Organization Name:DR. JONATHAN E JACK DC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-397-9531
Mailing Address - Street 1:2118 KETTERING RD
Mailing Address - Street 2:
Mailing Address - City:CREEKSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:15732-9237
Mailing Address - Country:US
Mailing Address - Phone:724-397-9531
Mailing Address - Fax:
Practice Address - Street 1:2118 KETTERING RD
Practice Address - Street 2:
Practice Address - City:CREEKSIDE
Practice Address - State:PA
Practice Address - Zip Code:15732-9237
Practice Address - Country:US
Practice Address - Phone:724-397-9531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 005990L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty