Provider Demographics
NPI:1265917611
Name:LOCK, JACK LESLIE (APRN FNP-BC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:LESLIE
Last Name:LOCK
Suffix:
Gender:M
Credentials:APRN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-0095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-3006
Practice Address - Country:US
Practice Address - Phone:870-456-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005934363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily