Provider Demographics
NPI:1639441850
Name:TSAN, JACK (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:TSAN
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 1:4708 BULL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-5506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8701 SHOAL CREEK BLVD STE 404
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6809
Practice Address - Country:US
Practice Address - Phone:512-879-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35206103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling