Provider Demographics
NPI:1508082082
Name:LATOW, JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LATOW
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 1:413 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3926
Mailing Address - Country:US
Mailing Address - Phone:530-661-1666
Mailing Address - Fax:
Practice Address - Street 1:413 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3926
Practice Address - Country:US
Practice Address - Phone:530-661-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY08259103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical