Healthcare Provider Details

I. General information

NPI: 1669471777
Provider Name (Legal Business Name): ALAN F JACKS, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 MALCOLM BLVD
RUTHERFORD COLLEGE NC
28671-0476
US

IV. Provider business mailing address

PO BOX 476
RUTHERFORD COLLEGE NC
28671-0476
US

V. Phone/Fax

Practice location:
  • Phone: 828-874-0555
  • Fax: 828-874-2111
Mailing address:
  • Phone: 828-874-0555
  • Fax: 828-874-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number96-01640
License Number StateNC

VIII. Authorized Official

Name: MR. ALAN F. JACKS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 828-874-0555