Provider Demographics
NPI:1942001177
Name:LUONG, JACK (DNP, CRNA, APRN)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LUONG
Suffix:
Gender:M
Credentials:DNP, CRNA, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47159
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-0159
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:763-450-3986
Practice Address - Street 1:14700 28TH AVE N STE 20
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4876
Practice Address - Country:US
Practice Address - Phone:763-559-3779
Practice Address - Fax:763-450-3986
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152725367500000X
MN3125367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered