Provider Demographics
NPI:1235327511
Name:BERRY, JACK T (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2902
Mailing Address - Country:US
Mailing Address - Phone:605-995-5756
Mailing Address - Fax:
Practice Address - Street 1:605 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2902
Practice Address - Country:US
Practice Address - Phone:605-995-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0488OtherSOUTH DAKOTA LICENSE #