Healthcare Provider Details

I. General information

NPI: 1780274191
Provider Name (Legal Business Name): JACK EUGENE SCOTT NP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 CRAIG RD
EAU CLAIRE WI
54701-6149
US

IV. Provider business mailing address

1004 SUSSEX DR
EAU CLAIRE WI
54703-2096
US

V. Phone/Fax

Practice location:
  • Phone: 715-858-4500
  • Fax:
Mailing address:
  • Phone: 715-797-0427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10295-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: