Provider Demographics
NPI:1295885788
Name:HEATH, JACK K (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:K
Last Name:HEATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-921-1600
Mailing Address - Fax:423-921-1681
Practice Address - Street 1:ROGERSVILLE MEDICAL COMPLEX
Practice Address - Street 2:4307 HIGHWAY 66 S
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3155
Practice Address - Country:US
Practice Address - Phone:423-921-1600
Practice Address - Fax:423-921-1681
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2018-06-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL18241207Q00000X
TN28163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F91460Medicare UPIN
TN38010701Medicare PIN