Provider Demographics
NPI:1518733443
Name:POPE, JACK RANDY
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:RANDY
Last Name:POPE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 FAIRVIEW AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-2752
Mailing Address - Country:US
Mailing Address - Phone:646-852-8651
Mailing Address - Fax:
Practice Address - Street 1:3251 THIRD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-6832
Practice Address - Country:US
Practice Address - Phone:347-236-9938
Practice Address - Fax:347-281-9138
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency