Provider Demographics
NPI:1710919097
Name:SIEGEL, JACK
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:SIEGEL
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 1:121 GRIFFITH PL
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-4211
Mailing Address - Country:US
Mailing Address - Phone:408-497-2258
Mailing Address - Fax:888-586-8609
Practice Address - Street 1:121 GRIFFITH PL
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-4211
Practice Address - Country:US
Practice Address - Phone:408-497-2258
Practice Address - Fax:888-586-8609
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist