MEDICARE: JONATHAN FREDERICK MACK N.P.

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	363L00000X	Nurse Practitioner	359079	CA
2	363LA2100X	Acute Care Nurse Practitioner	359079	CA

General Provider Information

NPI Number	:	1922230747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN FREDERICK MACK N.P.

Provider Business Mailing Address
First Line	:	6822 LAKE CT
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-7023
Country	:	US
Telephone Number	:	858-229-7232
Fax Number	:

Provider Business Practice Location Address
First Line	:	6822 LAKE CT
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-7023
Country	:	US
Telephone Number	:	858-229-7232
Fax Number	:

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

Provider Enumeration Date	:	08/12/2009
Last Update Date	:	08/12/2009

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