Individual
LISA JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8625 E 37TH ST N STE 101, WICHITA, KS 67226-2008
(316) 648-8545
Mailing address
5709 E 17TH ST N, WICHITA, KS 67208-1703
(316) 648-8545
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Enumeration date
06/14/2022
Last updated
06/14/2022
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