Provider Demographics
NPI:1417363748
Name:SAWYER, JACK ROBERT
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROBERT
Last Name:SAWYER
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 1:3116 LAKE DR APT 8
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-2833
Mailing Address - Country:US
Mailing Address - Phone:925-437-2780
Mailing Address - Fax:
Practice Address - Street 1:299 12TH ST
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-6003
Practice Address - Country:US
Practice Address - Phone:831-647-7918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor