Provider Demographics
NPI:1730250267
Name:JACK, JONATHAN JUTURU (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JUTURU
Last Name:JACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-0640
Mailing Address - Country:US
Mailing Address - Phone:252-536-5440
Mailing Address - Fax:252-536-5444
Practice Address - Street 1:270 SMITH CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870
Practice Address - Country:US
Practice Address - Phone:252-537-0134
Practice Address - Fax:252-537-6515
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5815819OtherVIRGINIA MEDICAID
82401OtherMEDCOST
NC8911276Medicaid
020384900OtherDIVISION OF COAL MINERS
NC11276OtherBCBSNC
VA028182OtherVABCBS
04 55332OtherUNITED HEALTHCARE
18619OtherCAPITOL BC PENN
110163886OtherRR MEDICARE PALMETTO
NC2247456Medicare ID - Type Unspecified
04 55332OtherUNITED HEALTHCARE