Provider Demographics
NPI:1134330947
Name:ANDERSON, JACK GLENN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:GLENN
Last Name:ANDERSON
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 1:200 E DEL MAR BLVD
Mailing Address - Street 2:SUITE 122
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2544
Mailing Address - Country:US
Mailing Address - Phone:626-792-8922
Mailing Address - Fax:626-792-6504
Practice Address - Street 1:200 E DEL MAR BLVD
Practice Address - Street 2:SUITE 122
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2544
Practice Address - Country:US
Practice Address - Phone:626-792-8922
Practice Address - Fax:626-792-6504
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical