Provider Demographics
NPI:1720165715
Name:JACK, MICHELLE A (RN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:JACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SEIDEN ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-822-7523
Mailing Address - Fax:
Practice Address - Street 1:1425 BLUE HILL AVENUE
Practice Address - Street 2:MATTAPAN COMMUNITY HEALTH CENTER
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126
Practice Address - Country:US
Practice Address - Phone:617-898-9013
Practice Address - Fax:617-296-1421
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252437163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse