Provider Demographics
NPI:1922523786
Name:JACK, LINDSEY NICOLE (CPNP)
Entity Type:Individual
Prefix:MISS
First Name:LINDSEY
Middle Name:NICOLE
Last Name:JACK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W. CHISHOLM
Mailing Address - Street 2:ATTN: PHYSICAN RELATIONS
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-13
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704315115363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics