Healthcare Provider Details

I. General information

NPI: 1497079875
Provider Name (Legal Business Name): DONALD RAY JACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 WILCOX AVE
HOLLYWOOD CA
90028-6206
US

IV. Provider business mailing address

180 E. PROVIDENCIA AVE.
BURBANK CA
91205
US

V. Phone/Fax

Practice location:
  • Phone: 424-202-0322
  • Fax:
Mailing address:
  • Phone: 424-202-0322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number12521464546464
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: