Basic Information
| Provider Information | |||||||||
| NPI: | 1528195815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | TAMECA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 CRENSHAW BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905031727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107871500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 370 CRENSHAW BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905031727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107871500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT83978 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 01536011 | 01 | CA | MEDI-CAL | OTHER |