Provider Demographics
NPI:1508334491
Name:SPITZACK, JACOB TIMOTHY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TIMOTHY
Last Name:SPITZACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 E 14TH AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8223
Mailing Address - Country:US
Mailing Address - Phone:651-403-2514
Mailing Address - Fax:
Practice Address - Street 1:360 S GARDEN WAY STE 250
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8175
Practice Address - Country:US
Practice Address - Phone:541-726-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10195019103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst