Healthcare Provider Details

I. General information

NPI: 1841972668
Provider Name (Legal Business Name): JONATHAN PAUL SACKS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NAVY PENTAGON
WASHINGTON DC
20350-0001
US

IV. Provider business mailing address

1708 W JARVIS AVE # 2
CHICAGO IL
60626-1606
US

V. Phone/Fax

Practice location:
  • Phone: 703-697-7391
  • Fax:
Mailing address:
  • Phone: 773-919-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: