Provider Demographics
NPI:1922230747
Name:MACK, JONATHAN FREDERICK (NP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:FREDERICK
Last Name:MACK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6822 LAKE CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7023
Mailing Address - Country:US
Mailing Address - Phone:858-229-7232
Mailing Address - Fax:
Practice Address - Street 1:6822 LAKE CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-7023
Practice Address - Country:US
Practice Address - Phone:858-229-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA359079363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care