Provider Demographics
NPI:1265937544
Name:PLOEGER, JACK HARRY (RN)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:HARRY
Last Name:PLOEGER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 STAR BATT DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3711
Mailing Address - Country:US
Mailing Address - Phone:248-844-9650
Mailing Address - Fax:
Practice Address - Street 1:1902 STAR-BATT DRIVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-4830
Practice Address - Country:US
Practice Address - Phone:248-844-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704301206163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health