Provider Demographics
NPI:1346308210
Name:ZIMMERMAN, JACK LAWERENCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LAWERENCE
Last Name:ZIMMERMAN
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 1:16244 S MILITARY TRAIL
Mailing Address - Street 2:SUITE 760
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484
Mailing Address - Country:US
Mailing Address - Phone:561-495-9083
Mailing Address - Fax:561-731-0052
Practice Address - Street 1:16244 S MILITARY TRAIL
Practice Address - Street 2:SUITE 760
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484
Practice Address - Country:US
Practice Address - Phone:561-495-9083
Practice Address - Fax:561-731-0052
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R99943Medicare UPIN
73049Medicare ID - Type Unspecified