Provider Demographics
NPI:1275990491
Name:MACK, JOVAN (FNP)
Entity Type:Individual
Prefix:
First Name:JOVAN
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 PARFET ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-5576
Mailing Address - Country:US
Mailing Address - Phone:303-986-9583
Mailing Address - Fax:
Practice Address - Street 1:6895 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-3047
Practice Address - Country:US
Practice Address - Phone:303-218-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992154-NP363LF0000X
NM53745207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily