Individual
JODY MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
947 S 5TH ST, MONTROSE, CO 81401-5716
(970) 249-2421
(970) 249-1203
Mailing address
947 S 5TH ST, MONTROSE, CO 81401-5716
(970) 249-2421
(970) 249-1203
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
2457
CO
363AM0700X
Medical Physician Assistant
Primary
MED-PAC-LIC-61430
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
67538746
—
CO
Enumeration date
11/14/2007
Last updated
03/03/2022
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