Provider Demographics
NPI:1669471777
Name:ALAN F JACKS, MD PA
Entity Type:Organization
Organization Name:ALAN F JACKS, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-874-0555
Mailing Address - Street 1:PO BOX 476
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671-0476
Mailing Address - Country:US
Mailing Address - Phone:828-874-0555
Mailing Address - Fax:828-874-2111
Practice Address - Street 1:845 MALCOLM BLVD
Practice Address - Street 2:
Practice Address - City:RUTHERFORD COLLEGE
Practice Address - State:NC
Practice Address - Zip Code:28671-0476
Practice Address - Country:US
Practice Address - Phone:828-874-0555
Practice Address - Fax:828-874-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-01640208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1013EOtherBCBS
NC5909135Medicaid
NC891013EMedicaid
NC96-01640OtherNC LICENSE
NC2233376AMedicare PIN
NC891013EMedicaid