MEDICARE: PROF. JAMES KYLE JACK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1205069234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. JAMES KYLE JACK PA-C

Provider Business Mailing Address
First Line	:	1331 N ELM ST
Second Line	:	SUITE 200
City	:	GREENSBORO
State	:	NC
Zip	:	27401-6302
Country	:	US
Telephone Number	:	336-274-9617
Fax Number	:	336-482-2177

Provider Business Practice Location Address
First Line	:	1555 SPRINGFIELD DR
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95928-6398
Country	:	US
Telephone Number	:	530-433-9633
Fax Number	:	530-433-9634

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2009
Last Update Date	:	01/29/2016

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Directions to “ PROF. JAMES KYLE JACK PA-C” Practice Location

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