Provider Demographics
NPI:1679560775
Name:FOREST, JACK L (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:FOREST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:114 E SOUTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2659
Mailing Address - Country:US
Mailing Address - Phone:660-562-2600
Mailing Address - Fax:660-562-7911
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-2600
Practice Address - Fax:660-562-7911
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA049972208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN
VA7313519Medicaid
VAC06695OtherGROUP PTAN
VA7313519Medicaid
VA7313519Medicaid