Provider Demographics
NPI:1801404306
Name:JACK, PATRICIA (RN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 EOFF ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-4420
Mailing Address - Country:US
Mailing Address - Phone:304-843-2306
Mailing Address - Fax:304-843-2308
Practice Address - Street 1:87 SWIERKOS DR
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-4209
Practice Address - Country:US
Practice Address - Phone:304-843-2306
Practice Address - Fax:304-843-2308
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV1255523494Medicaid
WV1356607394Medicaid
WV1710243753Medicaid
WV1114118973Medicaid