Provider Demographics
NPI:1346855053
Name:SAMATH, JACK ETHAN
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ETHAN
Last Name:SAMATH
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 1:14720 VICKERY PL
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-6038
Mailing Address - Country:US
Mailing Address - Phone:408-386-4147
Mailing Address - Fax:
Practice Address - Street 1:9535 OAKLEY LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-6101
Practice Address - Country:US
Practice Address - Phone:775-843-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician