Individual
JONATHAN FREDERICK MACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
N.P.
Contact information
Practice address
6822 LAKE CT, SAN DIEGO, CA 92111-7023
(858) 229-7232
Mailing address
6822 LAKE CT, SAN DIEGO, CA 92111-7023
(858) 229-7232
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
359079
CA
363LA2100X
Acute Care Nurse Practitioner
359079
CA
Other
Enumeration date
08/12/2009
Last updated
08/12/2009
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