Provider Demographics
NPI:1548691462
Name:JACK, NATASHA (LPN)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10544 FLATLANDS 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3020
Mailing Address - Country:US
Mailing Address - Phone:718-775-7723
Mailing Address - Fax:
Practice Address - Street 1:10544 FLATLANDS 3RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3020
Practice Address - Country:US
Practice Address - Phone:718-775-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317178164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse