Provider Demographics
NPI:1073178745
Name:WHITTAKER, JACK THOMAS
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:THOMAS
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 SW SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3502
Mailing Address - Country:US
Mailing Address - Phone:503-505-0739
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5102
Practice Address - Country:US
Practice Address - Phone:510-679-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician