Nicole M. Jack, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

085006579 Issued in IL

Practice address

2500 W Reynolds St
Pontiac, IL 61764

Phone

(815) 844-5343

Fax

(815) 844-5715

NPI assigned

May 15, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2017

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Memorial Physician ServicesGroup PAC ID 9032005681, 161 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Memorial Medical Center Hospital, Springfield, IL, CCN 140148

Merit-based Incentive Payment System (MIPS)

Final score

79.44 of 100Reported as group

Quality

71.79

Promoting interoperability

77

Improvement activities

40

Cost

75.71

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: nicolejack@memorial.allscriptsdirect.net
• Direct secure messaging: nicolejack@sfc.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Memorial Physician Services

  • Family Medicine Physician
  • Springfield, IL
  • NPI 1174877930

  Physician Assistant

  Medicare reassignment Care Compare group NPD
• Family Medical Center of Chatham, LLC

  • Family Medicine Physician
  • Chatham, IL
  • NPI 1992956528
  NPD
• Memorial Health Partners

  • Family Medicine Physician
  • Springfield, IL
  • NPI 1376034744
  NPD
• Memorial Physician Services

  • Rural Health Clinic/Center
  • Jacksonville, IL
  • NPI 1528741147
  NPD
• Springfield Clinic LLP

  • Multi-Specialty Clinic/Center
  • Springfield, IL
  • NPI 1215974415
  NPD
• Memorial Expresscare, LLC

  • Family Medicine Physician
  • Springfield, IL
  • NPI 1750532362
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Memorial Medical Center

  • General Acute Care Hospital
  • Springfield, IL
  • NPI 1255317590
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1526342400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1529280000000",
    "number": "1083104137",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2500 W REYNOLDS ST",
            "city": "PONTIAC",
            "state": "IL",
            "postal_code": "617649774",
            "telephone_number": "815-844-5343",
            "fax_number": "815-844-5715"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2500 W REYNOLDS ST",
            "city": "PONTIAC",
            "state": "IL",
            "postal_code": "61764",
            "telephone_number": "815-844-5343",
            "fax_number": "815-844-5715"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACK",
        "first_name": "NICOLE",
        "middle_name": "M.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-05-15",
        "last_updated": "2018-06-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085006579",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alexandra Hume
• Institute for Human Resources
• Institute for Human Resources of Livingston County, Il
• J a K Enterprises Inc (Bard Optical)
• J C Purnell MD SC
• Heather Ann Taylor Jackson, APRN, WHNP-BC
• John W. Rinker
• Andrew D Jordan, DDS
• Kenneth N Jordan, DO
• Arianne M Kaack, PHARMD

• Physician Assistant in Pontiac, IL
• Providers in Pontiac, IL by specialty
• Physician Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.