Provider Demographics
NPI:1467484402
Name:ACKERMAN, JOHN ROBERT (MFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 CAMINO MIRA COSTA
Mailing Address - Street 2:SUITE K
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3529
Mailing Address - Country:US
Mailing Address - Phone:949-606-5398
Mailing Address - Fax:
Practice Address - Street 1:3551 CAMINO MIRA COSTA
Practice Address - Street 2:SUITE K
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3508
Practice Address - Country:US
Practice Address - Phone:949-606-5398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist