Provider Demographics
NPI:1407578891
Name:WHITE, JACK (CRM , THW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:CRM , THW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 S EMPIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-3374
Mailing Address - Country:US
Mailing Address - Phone:541-851-7151
Mailing Address - Fax:
Practice Address - Street 1:1741 NEWMARK AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4704
Practice Address - Country:US
Practice Address - Phone:541-851-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-CRM-1099175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000107022OtherTHW