Healthcare Provider Details

I. General information

NPI: 1194053496
Provider Name (Legal Business Name): JACK MONCRIEF GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WEST 34TH STREET SUITE 101
AUSTIN TX
78705
US

IV. Provider business mailing address

800 WEST 34TH STREET SUITE 101
AUSTIN TX
78705
US

V. Phone/Fax

Practice location:
  • Phone: 512-485-7870
  • Fax: 512-485-7876
Mailing address:
  • Phone: 512-485-7870
  • Fax: 512-485-7876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK WESLY MONCRIEF
Title or Position: OWNER
Credential: MD
Phone: 512-485-7870