Provider Demographics
NPI:1497961635
Name:CRIBB, JACK EDISON (DO)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:EDISON
Last Name:CRIBB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-7756
Mailing Address - Country:US
Mailing Address - Phone:517-652-1059
Mailing Address - Fax:
Practice Address - Street 1:3618 BENTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-7756
Practice Address - Country:US
Practice Address - Phone:517-652-1059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1769156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine