Provider Demographics
NPI:1669461869
Name:PRICE, JACK DONATHAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:DONATHAN
Last Name:PRICE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:6606 LBJ FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX650845367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8610UJOtherBCBS
TXP01446643OtherRR
TX1424954-01Medicaid
TX142495408Medicaid
TXP01446643OtherRR
TX8610UJOtherBCBS
P23913Medicare UPIN
TX142495408Medicaid