Provider Demographics
NPI:1518481993
Name:LOCKHART, JACK DOUGLAS
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DOUGLAS
Last Name:LOCKHART
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 1:10717 CAMINO RUIZ STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2364
Mailing Address - Country:US
Mailing Address - Phone:858-695-2211
Mailing Address - Fax:858-695-3521
Practice Address - Street 1:10717 CAMINO RUIZ STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2364
Practice Address - Country:US
Practice Address - Phone:858-695-2211
Practice Address - Fax:858-695-3521
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-CWYSEG175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist