Provider Demographics
NPI:1710966593
Name:ITO, JACK WARREN (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WARREN
Last Name:ITO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:WARREN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:29 PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277
Mailing Address - Country:US
Mailing Address - Phone:760-830-2782
Mailing Address - Fax:724-407-1201
Practice Address - Street 1:NAVAL HOSPITAL 29 PALMS
Practice Address - Street 2:MCAGCC
Practice Address - City:29 PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008530L103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA016536380004Medicaid
PA163751OtherVALUE BEHAVIORAL HEALTH
PA959098OtherHIGHMARK PROVIDER NUMBER
PAA771081OtherVALUE BEHAVIORAL HEALTH
PA163751OtherVALUE BEHAVIORAL HEALTH
PAMA959098Medicare ID - Type Unspecified