Provider Demographics
NPI:1801926035
Name:SUMMERS, JACK PEARSON (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:PEARSON
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 W BUCKSKIN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-9126
Mailing Address - Country:US
Mailing Address - Phone:208-233-8209
Mailing Address - Fax:
Practice Address - Street 1:5418 W BUCKSKIN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-9126
Practice Address - Country:US
Practice Address - Phone:208-233-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine