Provider Demographics
NPI:1730211129
Name:JACK, DEBRA C (RN)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:C
Last Name:JACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 W CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-1809
Mailing Address - Country:US
Mailing Address - Phone:407-760-0195
Mailing Address - Fax:407-482-4486
Practice Address - Street 1:832 W CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1809
Practice Address - Country:US
Practice Address - Phone:407-760-0195
Practice Address - Fax:407-482-4486
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3224602163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health