Provider Demographics
NPI:1407629777
Name:WAITES, JACK R III
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:R
Last Name:WAITES
Suffix:III
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 1:155 BIMINI PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-5902
Mailing Address - Country:US
Mailing Address - Phone:213-388-5423
Mailing Address - Fax:
Practice Address - Street 1:155 BIMINI PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-5902
Practice Address - Country:US
Practice Address - Phone:213-388-5423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)