Provider Demographics
NPI:1801340526
Name:TERRY, JACK E (OD, PHD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:TERRY
Suffix:
Gender:M
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2012
Mailing Address - Country:US
Mailing Address - Phone:704-887-0824
Mailing Address - Fax:704-332-9568
Practice Address - Street 1:200 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2012
Practice Address - Country:US
Practice Address - Phone:704-887-0824
Practice Address - Fax:704-332-9568
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1469152W00000X
OH5608152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC057645OtherOE TRACKER