| NPI | 1740515790 |
|---|---|
| Other Name | JACK WAYNE ETHERIDGE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner Psychiatric/Mental Health (Licence: LA AP05657) |
| Enumeration Date | 2009-10-08 |
| Last Update Date | 2009-10-08 |