Provider Demographics
NPI:1780040808
Name:WISE, JACK (DC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WISE
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 1:701 E BROWARD BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2022
Mailing Address - Country:US
Mailing Address - Phone:217-494-3643
Mailing Address - Fax:
Practice Address - Street 1:701 E BROWARD BLVD STE D
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2022
Practice Address - Country:US
Practice Address - Phone:217-494-3643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor