Healthcare Provider Details

I. General information

NPI: 1376002931
Provider Name (Legal Business Name): JACK CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CENTER ST
WATERTOWN MA
02472-4018
US

IV. Provider business mailing address

30 CENTER ST
WATERTOWN MA
02472-4018
US

V. Phone/Fax

Practice location:
  • Phone: 617-393-1709
  • Fax: 617-754-6420
Mailing address:
  • Phone: 617-393-1709
  • Fax: 617-754-6420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: CODEY GILLUM
Title or Position: CEO
Credential: PA-C
Phone: 617-754-5000