Active NPI
Jeffery Thomas Jack, RN
- Critical Care Medicine Registered Nurse
- Wichita, KS
National Provider Identifier
1295568509
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Critical Care Medicine Registered Nurse
- License
- 13-74692-081
- Practice address
- 5500 W Kellogg Dr
Wichita, KS 67209-2345 - Phone
- (316) 685-2221
- Fax
- (316) 681-5599
- NPI assigned
- Aug 22, 2024
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ambulatory Care Registered Nurse | 163WP2201X | 13-74692-081 | KS | |
| Critical Care Medicine Registered Nurse | 163WC0200X | 13-74692-081 | KS | Primary |
Addresses
Primary practice location
5500 W Kellogg Dr
Wichita, KS 67209-2345
Mailing address
5500 W Kellogg Dr
Wichita, KS 67209-2345
Phone (316) 685-2221
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 13-74692-081 | KS | MD | Critical Care Medicine Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1724284800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1724284800000",
"number": "1295568509",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5500 W KELLOGG DR",
"city": "WICHITA",
"state": "KS",
"postal_code": "672092345",
"telephone_number": "316-685-2221",
"fax_number": "316-681-5599"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5500 W KELLOGG DR",
"city": "WICHITA",
"state": "KS",
"postal_code": "672092345",
"telephone_number": "316-685-2221",
"fax_number": "316-681-5599"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACK",
"first_name": "JEFFERY",
"middle_name": "THOMAS",
"name_prefix": "Mr.",
"credential": "RN",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2024-08-22",
"last_updated": "2024-08-22",
"certification_date": "2024-08-22",
"status": "A"
},
"taxonomies": [
{
"code": "163WP2201X",
"taxonomy_group": "",
"desc": "Registered Nurse, Ambulatory Care",
"state": "KS",
"license": "13-74692-081",
"primary": false
},
{
"code": "163WC0200X",
"taxonomy_group": "",
"desc": "Registered Nurse, Critical Care Medicine",
"state": "KS",
"license": "13-74692-081",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wichita, KS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.