NICOLE M. JACK (NPI# 1083104137) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1083104137 |
| Entity Type | Individual |
| Full Name | NICOLE M. JACK |
| Credential | PA-C |
| Practice Address |
2500 W Reynolds St Pontiac IL 61764 |
| Mailing Address |
2500 W Reynolds St Pontiac IL 61764-9774 |
| Practice Telephone | 8158445343 |
| Practice Fax Number | 8158445715 |
| Mailing Telephone | 8158445343 |
| Mailing Fax Number | 8158445715 |
| Enumeration Date | 2018-05-15 |
| Last Update Date | 2018-06-18 |
| Gender Code | F |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363A00000X | Physician Assistant | 085006579 | IL | Physician Assistants & Advanced Practice Nursing Providers |
| Street Address |
2500 W REYNOLDS ST |
| City | PONTIAC |
| State | IL |
| Zip Code | 61764 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1790735421 | Saint James Hospital | Emergency Medicine | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2006-05-11 |
| 1003421660 | Emily Ruff | Occupational Therapist | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2020-09-10 |
| 1760012637 | Stacey M Merrill | Nurse Practitioner | 2500 W Reynolds St, Pontiac, IL 61764-9784 | 2020-01-20 |
| 1699325514 | Brittany Nicole Bursott | Nurse Practitioner | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2019-09-12 |
| 1912561960 | Tessa Claire Hayes | Nurse Practitioner | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2019-04-25 |
| 1346708435 | Karissa Ann Neihouser | Physical Therapist | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2019-03-07 |
| 1659848612 | Melissa Horning | Specialist/Technologist | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2018-10-29 |
| 1497221840 | Allison Lynn Perkins | Occupational Therapist | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2018-10-23 |
| 1255818258 | Justin Ray Hayes | Registered Nurse | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2018-07-23 |
| 1154828440 | Lorrie R. Harmon | Nurse Practitioner | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2018-04-12 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1497165211 | Barbara Kay Browning | Counselor | 310 E. Torrance Ave, Pontiac, IL 61764 | 2014-05-01 |
| 1407287121 | Institute for Human Resources of Livingston County, Il | Community/Behavioral Health | 301 E Torrance Ave, Pontiac, IL 61764 | 2013-12-05 |
| 1982031241 | Annette G Franzen | Psychologist | 700 W Lincoln St # 406, Pontiac, IL 61764 | 2013-10-02 |
| 1871739185 | Woodridge of Ponitac LLC | Assisted Living Facility | 120 North Deerfield Road, Pontiac, IL 61764 | 2008-12-17 |
| 1861601171 | William Earl Hammond | Chiropractor | 210b Ladd, Pontiac, IL 61764 | 2007-05-22 |
| 1932259983 | Amy Duffy | Counselor | 210 W Water St Ste 1, Pontiac, IL 61764 | 2007-01-11 |
| 1326123340 | Highland Park Cvs, L.L.C. | Durable Medical Equipment & Medical Supplies | 1034 W. Reynolds Street, Pontiac, IL 61764 | 2006-10-26 |
| 1205932977 | Gary Merl Leverton | Dentist | 518 West Madison St, Pontiac, IL 61764 | 2006-09-16 |
| 1891899886 | Robert E Heins | Family Medicine | 520 West Madison, Madison Street Clinic PC, Pontiac, IL 61764 | 2006-09-11 |
| 1710081708 | Kenneth N Jordan | Family Medicine | 520 West Madison Street, Madison Street Clinic PC, Pontiac, IL 61764 | 2006-09-11 |
| Find all providers in zip 61764 | ||||
| Taxonomy Code | 363A00000X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Physician Assistant |
| A physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and is practicing within the scope of that license. Physician assistants are formally trained to perform many of the routine, time-consuming tasks a physician can do. In some states, they may prescribe medications. They take medical histories, perform physical exams, order lab tests and x-rays, and give inoculations. Most states require that they work under the supervision of a physician. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1548877400 | Shawn Milhauser | Physician Assistant | 1014 N Mill St, Pontiac, IL 61764-1332 | 2020-09-25 |
| 1265901755 | Rachel Harrington | Physician Assistant | 50 N Perry St, Pontiac, MI 48342-2217 | 2018-11-14 |
| 1497257745 | Robert Edward Van Meter | Physician Assistant | 2500 W Reynolds St, Pontiac, IL 61764 | 2018-03-02 |
| 1821522566 | Briana Stebbins | Physician Assistant | 44405 Woodward Ave, Pontiac, MI 48341-5023 | 2017-04-19 |
| 1164827994 | Rachel Kuisell | Physician Assistant | 585 South Blvd E Ste 100, Pontiac, MI 48341-3163 | 2014-10-22 |
| 1699180554 | Stephanie Nicole Stewart | Physician Assistant | 44405 Woodward Ave, Pontiac, MI 48341-5023 | 2014-06-30 |
| 1619227048 | Heather Hall | Physician Assistant | 50 N Perry St, Pontiac, MI 48342-2217 | 2012-09-13 |
| 1144502394 | Sally Jajou | Physician Assistant | 44405 Woodward Ave, Pontiac, MI 48341-5023 | 2011-09-14 |
| 1215235007 | Danielle Vanderveen | Physician Assistant | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2011-03-03 |
| 1023326121 | William Lee Chang II | Physician Assistant | 2500 W Reynolds St, Pontiac, IL 61764-9774 | 2010-09-23 |
| Find all providers in PONTIAC | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.