Provider Demographics
NPI:1427002369
Name:PRUETT, JACK B (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:PRUETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BIRMINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-5461
Mailing Address - Country:US
Mailing Address - Phone:205-384-4585
Mailing Address - Fax:205-384-4428
Practice Address - Street 1:1800 BIRMINGHAM AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5461
Practice Address - Country:US
Practice Address - Phone:205-384-4585
Practice Address - Fax:205-384-4428
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12412207P00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D97142Medicare UPIN