Healthcare Provider Details

I. General information

NPI: 1992987713
Provider Name (Legal Business Name): ALAN FOWLER JACKS M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 MALCOLM BLVD.
CONNELLY SPRINGS NC
28612
US

IV. Provider business mailing address

845 MALCOLM BLVD.
CONNELLY SPRINGS NC
28612
US

V. Phone/Fax

Practice location:
  • Phone: 828-580-3555
  • Fax: 828-874-2111
Mailing address:
  • Phone: 828-580-3555
  • Fax: 828-874-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9601640
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: