Individual
NICOLE M. JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2500 W REYNOLDS ST, PONTIAC, IL 61764
(815) 844-5343
(815) 844-5715
Mailing address
2500 W REYNOLDS ST, PONTIAC, IL 61764-9774
(815) 844-5343
(815) 844-5715
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085006579
IL
Other
Enumeration date
05/15/2018
Last updated
06/18/2018
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