Provider Demographics
NPI:1518910892
Name:JACK, JASON M (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:JACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2000 STONEGATE TRL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2246
Mailing Address - Country:US
Mailing Address - Phone:205-298-8660
Mailing Address - Fax:205-298-8664
Practice Address - Street 1:2000 STONEGATE TRL
Practice Address - Street 2:SUITE 100
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-2246
Practice Address - Country:US
Practice Address - Phone:205-298-8660
Practice Address - Fax:205-298-8664
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-10-20
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Provider Licenses
StateLicense IDTaxonomies
AL00026747208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51591946OtherBCBS OF AL
AL51040131OtherBCBS OF AL
AL51591941OtherBCBS OF AL
AL51591942OtherBCBS OF AL
AL51591941OtherBCBS OF AL