Organization
JACK CITY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CODEY GILLUM PA-C (CEO)
(617) 754-5000
Entity
Organization
Contact information
Practice address
30 CENTER ST, WATERTOWN, MA 02472-4018
(617) 393-1709
(617) 754-6420
Mailing address
30 CENTER ST, WATERTOWN, MA 02472-4018
(857) 760-7374
(617) 754-6420
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
363AS0400X
Surgical Physician Assistant
—
—
Other
Enumeration date
03/13/2019
Last updated
04/20/2026
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