Provider Demographics
NPI:1205069234
Name:JACK, JAMES KYLE (PA-C)
Entity type:Individual
Prefix:PROF
First Name:JAMES
Middle Name:KYLE
Last Name:JACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:PROF
Other - First Name:KYLE
Other - Middle Name:
Other - Last Name:JACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1555 SPRINGFIELD DR
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-6398
Practice Address - Country:US
Practice Address - Phone:530-433-9633
Practice Address - Fax:530-433-9634
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant