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NPI Code Detail

MEDICARE: DR. ALEXA BRIANNA NICOLE JACK MD

MEDICARE: DR. ALEXA BRIANNA NICOLE JACK MD
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
1390200000XStudent in an Organized Health Care Education/Training ProgramNY

General Provider Information

NPI Number : 1699612200
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ALEXA BRIANNA NICOLE JACK MD
Provider Business Mailing Address
First Line : 327 BEACH 19TH ST
Second Line :
City : FAR ROCKAWAY
State : NY
Zip : 11691-4423
Country : US
Telephone Number : 718-869-7000
Fax Number :
Provider Business Practice Location Address
First Line : 327 BEACH 19TH ST
Second Line :
City : FAR ROCKAWAY
State : NY
Zip : 11691-4423
Country : US
Telephone Number : 718-869-7107
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2026
Last Update Date : 05/01/2026

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