Basic Information
| Provider Information | |||||||||
| NPI: | 1669442075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | MARILOU | ||||||||
| MiddleName: | REYES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 HOSPITAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | BEATRICE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683106906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022283344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 HOSPITAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | BEATRICE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683106906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022283344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD26013 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.