=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093744989
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACK H. HENRY MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4004 82ND ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79423-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-792-5500
-----------------------------------------------------
Fax | 806-722-3103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16585
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79490-6585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-785-2045
-----------------------------------------------------
Fax | 806-785-0872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COORDINATOR, MANAGED CARE
-----------------------------------------------------
Name | MR. CLAY P GARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-785-7676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | D1880
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------