MEDICARE: TUNYA S. JACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	204007	LA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1077321	TX

General Provider Information

NPI Number	:	1508324047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TUNYA S. JACK

Provider Business Mailing Address
First Line	:	1241 SHADYBROOK DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-1273
Country	:	US
Telephone Number	:	225-485-1797
Fax Number	:

Provider Business Practice Location Address
First Line	:	1241 SHADYBROOK DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-1273
Country	:	US
Telephone Number	:	225-485-1797
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	12/11/2024

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