Provider Demographics
NPI:1871180117
Name:JUSTICE, JACK CLAUDIOUS III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:CLAUDIOUS
Last Name:JUSTICE
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 BOONES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4432
Mailing Address - Country:US
Mailing Address - Phone:423-782-0243
Mailing Address - Fax:
Practice Address - Street 1:2244 BOONES CREEK RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4432
Practice Address - Country:US
Practice Address - Phone:423-782-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant