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NPI Code Detail

MEDICARE: MRS. ALEXANDRA M JACK RD

MEDICARE: MRS. ALEXANDRA M JACK RD
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
1133V00000XRegistered Dietitian560OR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1972674083
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ALEXANDRA M JACK RD
Provider Business Mailing Address
First Line : 8716 E MILL PLAIN BLVD
Second Line : SPECIALTY CLINICS BUILDING
City : VANCOUVER
State : WA
Zip : 98664-2531
Country : US
Telephone Number : 360-514-7932
Fax Number :
Provider Business Practice Location Address
First Line : 8716 E MILL PLAIN BLVD
Second Line : SPECIALTY CLINICS BUILDING
City : VANCOUVER
State : WA
Zip : 98664-2531
Country : US
Telephone Number : 360-514-7932
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/11/2006
Last Update Date : 10/10/2013

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Directions to “ MRS. ALEXANDRA M JACK RD” Practice Location

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