Provider Demographics
NPI:1013229020
Name:DUTRO, JACK W (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:DUTRO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2838
Mailing Address - Country:US
Mailing Address - Phone:360-537-9103
Mailing Address - Fax:360-532-8891
Practice Address - Street 1:1210 MADISON ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2838
Practice Address - Country:US
Practice Address - Phone:360-537-9103
Practice Address - Fax:360-532-8891
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00000951106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist