Provider Demographics
NPI:1437282621
Name:BRITO, JACK (MS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BRITO
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6153 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4516
Mailing Address - Country:US
Mailing Address - Phone:323-890-2908
Mailing Address - Fax:
Practice Address - Street 1:12714 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2730
Practice Address - Country:US
Practice Address - Phone:323-777-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF52205101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health