Provider Demographics
NPI:1639857162
Name:MORKIN, JACK CHARLES
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CHARLES
Last Name:MORKIN
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 1:11 SCOFIELD CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4809
Mailing Address - Country:US
Mailing Address - Phone:309-824-6952
Mailing Address - Fax:
Practice Address - Street 1:119 N WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3528
Practice Address - Country:US
Practice Address - Phone:309-663-1326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0344461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty