Provider Demographics
NPI:1730114174
Name:JACK, JONATHAN ELLIOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ELLIOTT
Last Name:JACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 KETTERING RD
Mailing Address - Street 2:
Mailing Address - City:CREEKSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:15732-9237
Mailing Address - Country:US
Mailing Address - Phone:724-397-9531
Mailing Address - Fax:
Practice Address - Street 1:2118 KETTERING RD
Practice Address - Street 2:
Practice Address - City:CREEKSIDE
Practice Address - State:PA
Practice Address - Zip Code:15732-9237
Practice Address - Country:US
Practice Address - Phone:724-397-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005990L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor