Provider Information for 1306591342
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MARCUS JACK
Sex: Male
NPI: 1306591342
Last Updated: 2022-02-17
Certification Date: 2022-02-17
Certification Date: 2022-02-17
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1306591342 | ||||||||
| Enumeration Date | 2022-02-17 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 5640 STONE CT STONE MOUNTAIN, GA 30087-2954 United States Phone: 770-912-5225 | Fax: | ||||||||
| Primary Practice Address | 12400 S MICHIGAN AVE CHICAGO, IL 60628-7347 United States Phone: 770-912-5225 | Fax: | ||||||||
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