Provider Demographics
NPI:1376002931
Name:JACK CITY, LLC
Entity Type:Organization
Organization Name:JACK CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CODEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILLUM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:617-393-1709
Mailing Address - Street 1:290 PLEASANT ST APT 212
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2429
Mailing Address - Country:US
Mailing Address - Phone:617-393-1709
Mailing Address - Fax:617-754-6420
Practice Address - Street 1:251 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4143
Practice Address - Country:US
Practice Address - Phone:617-393-1709
Practice Address - Fax:617-754-6420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty