Provider Demographics
NPI:1801378096
Name:ALEXANDER, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ALEXANDER
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 1:6 JULIET LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1317
Mailing Address - Country:US
Mailing Address - Phone:631-897-7133
Mailing Address - Fax:
Practice Address - Street 1:120 WOODBINE AVE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2897
Practice Address - Country:US
Practice Address - Phone:631-897-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006270171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist