Provider Demographics
NPI:1437284239
Name:LEVINE, JACK SANFORD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:SANFORD
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:750 TERRADO PLZ
Mailing Address - Street 2:SUITE 246
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3419
Mailing Address - Country:US
Mailing Address - Phone:626-915-0933
Mailing Address - Fax:626-339-2885
Practice Address - Street 1:750 TERRADO PLZ
Practice Address - Street 2:SUITE 246
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3419
Practice Address - Country:US
Practice Address - Phone:626-915-0933
Practice Address - Fax:626-339-2885
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6826103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP6826Medicare ID - Type Unspecified