Provider Demographics
NPI:1295568509
Name:JACK, JEFFERY THOMAS (RN)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:THOMAS
Last Name:JACK
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 1:5500 W KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-2345
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:316-681-5599
Practice Address - Street 1:5500 W KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2345
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:316-681-5599
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-74692-081163WP2201X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care