Provider Demographics
NPI:1780895342
Name:CARR, JACK NEERKEN (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:NEERKEN
Last Name:CARR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2750 BARFIELD DRIVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5570
Mailing Address - Country:US
Mailing Address - Phone:616-308-7826
Mailing Address - Fax:
Practice Address - Street 1:3353 LOUSMA DRIVE SE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-2251
Practice Address - Country:US
Practice Address - Phone:616-454-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010247682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B46489Medicare UPIN