Provider Demographics
NPI:1184698698
Name:JACK, JOANI L (MD)
Entity type:Individual
Prefix:
First Name:JOANI
Middle Name:L
Last Name:JACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 BLACKFORD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-1405
Mailing Address - Country:US
Mailing Address - Phone:423-778-6012
Mailing Address - Fax:423-778-6958
Practice Address - Street 1:910 BLACKFORD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1405
Practice Address - Country:US
Practice Address - Phone:423-778-6012
Practice Address - Fax:423-778-6958
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24883208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G72897Medicare UPIN
TN3828899Medicare ID - Type Unspecified