Provider Demographics
NPI:1609169200
Name:MACK, JASON D (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:MACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 WIND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4149
Mailing Address - Country:US
Mailing Address - Phone:715-675-3391
Mailing Address - Fax:
Practice Address - Street 1:425 WIND RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4149
Practice Address - Country:US
Practice Address - Phone:715-675-3391
Practice Address - Fax:715-675-5255
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine