Provider Demographics
NPI:1407904873
Name:WEITZ, JACK ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROBERT
Last Name:WEITZ
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 1:1021 IVES DARRY RD
Mailing Address - Street 2:BLDG 3 SUITE 119
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179
Mailing Address - Country:US
Mailing Address - Phone:305-655-2335
Mailing Address - Fax:305-652-5759
Practice Address - Street 1:1021 IVES DARRY RD
Practice Address - Street 2:BLDG 3 SUITE 119
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179
Practice Address - Country:US
Practice Address - Phone:305-655-2335
Practice Address - Fax:305-652-5759
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 4345103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73884Medicare ID - Type Unspecified