Provider Demographics
NPI:1992198188
Name:NI, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:NI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 HIATUS RD
Mailing Address - Street 2:PE DEPT - WEST REGION
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:888-447-2362
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:BAYLOR SCOTT & WHITE ALL SAINTS MEDICAL CENTER
Practice Address - Street 2:1400 8TH AVE
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4192
Practice Address - Country:US
Practice Address - Phone:817-926-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4609207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program