Provider Demographics
NPI:1720161607
Name:KRYSTYN, JACK PHIL JR (RN)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:PHIL
Last Name:KRYSTYN
Suffix:JR
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 1:184 CARAVAN LN
Mailing Address - Street 2:
Mailing Address - City:KINSEY
Mailing Address - State:AL
Mailing Address - Zip Code:36303-7694
Mailing Address - Country:US
Mailing Address - Phone:334-678-8268
Mailing Address - Fax:
Practice Address - Street 1:184 CARAVAN LN
Practice Address - Street 2:
Practice Address - City:KINSEY
Practice Address - State:AL
Practice Address - Zip Code:36303-7694
Practice Address - Country:US
Practice Address - Phone:334-678-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-03341163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency