Provider Demographics
NPI:1760663140
Name:MACK, JODY (PA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:
Other - Last Name:RUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:947 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5716
Mailing Address - Country:US
Mailing Address - Phone:970-249-2421
Mailing Address - Fax:970-249-1203
Practice Address - Street 1:947 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5716
Practice Address - Country:US
Practice Address - Phone:970-249-2421
Practice Address - Fax:970-249-1203
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2457363A00000X
MTMED-PAC-LIC-61430363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67538746Medicaid
CO67538746Medicaid