Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | C5724 | AR |
NPI | 1013909316 |
---|---|
Provider Name | Dr. Dennis W Jacks |
First Address | Pine Bluff, AR 71603-6329 |
Second Address | Pine Bluff, AR 71603-6329 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2005 |
Last Update Date | 03/11/2016 |