Healthcare Provider Details

I. General information

NPI: 1255278990
Provider Name (Legal Business Name): JACK MAVERICK O'HARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MANNING DR
CHAPEL HILL NC
27599-7595
US

IV. Provider business mailing address

590 MANNING DR
CHAPEL HILL NC
27599-7595
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-4888
  • Fax:
Mailing address:
  • Phone: 984-974-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number337870
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: