Provider Demographics
NPI:1548849623
Name:SUTCLIFFE, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SUTCLIFFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9699 OCEAN HWY
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-7425
Mailing Address - Country:US
Mailing Address - Phone:612-616-5529
Mailing Address - Fax:843-237-0495
Practice Address - Street 1:9699 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7425
Practice Address - Country:US
Practice Address - Phone:843-237-4296
Practice Address - Fax:843-237-0495
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91083207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine