Provider Demographics
NPI:1073579496
Name:GREESON, JACK (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GREESON
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:PO BOX 4953
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903
Mailing Address - Country:US
Mailing Address - Phone:361-578-9190
Mailing Address - Fax:361-578-9206
Practice Address - Street 1:5606 N NAVARRO
Practice Address - Street 2:STE 209
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904
Practice Address - Country:US
Practice Address - Phone:361-578-9190
Practice Address - Fax:361-578-9206
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22550103T00000X
TX6484103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81518PMedicare ID - Type Unspecified
R70017Medicare UPIN