Healthcare Provider Details

I. General information

NPI: 1295568509
Provider Name (Legal Business Name): JEFFERY THOMAS JACK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 W KELLOGG DR
WICHITA KS
67209-2345
US

IV. Provider business mailing address

5500 W KELLOGG DR
WICHITA KS
67209-2345
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax: 316-681-5599
Mailing address:
  • Phone: 316-685-2221
  • Fax: 316-681-5599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number13-74692-081
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number13-74692-081
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: