Provider Demographics
NPI:1477635639
Name:FUTTERMAN, JACK R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:FUTTERMAN
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 1:441 N MAIN ST
Mailing Address - Street 2:MODOC COUNTY MENTAL HEALTH
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101
Mailing Address - Country:US
Mailing Address - Phone:530-233-6312
Mailing Address - Fax:530-233-5311
Practice Address - Street 1:441 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101
Practice Address - Country:US
Practice Address - Phone:530-233-6312
Practice Address - Fax:530-233-5311
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10885103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral