Provider Demographics
NPI:1235267071
Name:MASLOW, JACK WARREN (MSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:WARREN
Last Name:MASLOW
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1411
Mailing Address - Country:US
Mailing Address - Phone:415-454-7698
Mailing Address - Fax:415-924-4456
Practice Address - Street 1:1030 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1411
Practice Address - Country:US
Practice Address - Phone:415-454-7698
Practice Address - Fax:415-924-4456
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS3629101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health