Provider Demographics
NPI:1811565542
Name:JACK, CHRISTINA ELAINE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ELAINE
Last Name:JACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5341 CLEAR FORK RD
Mailing Address - Street 2:
Mailing Address - City:DOROTHY
Mailing Address - State:WV
Mailing Address - Zip Code:25060-9600
Mailing Address - Country:US
Mailing Address - Phone:681-422-1806
Mailing Address - Fax:
Practice Address - Street 1:5341 CLEAR FORK RD
Practice Address - Street 2:
Practice Address - City:DOROTHY
Practice Address - State:WV
Practice Address - Zip Code:25060-9600
Practice Address - Country:US
Practice Address - Phone:681-422-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant