Provider Demographics
NPI:1699827881
Name:WACKS, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:WACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BEDFORD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4320
Mailing Address - Country:US
Mailing Address - Phone:781-861-6767
Mailing Address - Fax:781-861-6953
Practice Address - Street 1:35 BEDFORD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4320
Practice Address - Country:US
Practice Address - Phone:781-861-6767
Practice Address - Fax:781-861-6953
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA287832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB14041Medicare ID - Type Unspecified