Healthcare Provider Details

I. General information

NPI: 1750919924
Provider Name (Legal Business Name): DEBORAH ANTHONY JACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 06/18/2023
Certification Date: 06/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11890 HEALING WAY
SILVER SPRING MD
20904-7917
US

IV. Provider business mailing address

11013 LAKE VICTORIA LN
BOWIE MD
20720-4272
US

V. Phone/Fax

Practice location:
  • Phone: 240-637-4000
  • Fax:
Mailing address:
  • Phone: 240-281-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0097198
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: