Provider Demographics
NPI:1740524792
Name:KAHN, JACK S (PHD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
Last Name:KAHN
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 1:517 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-5412
Mailing Address - Country:US
Mailing Address - Phone:559-492-8358
Mailing Address - Fax:
Practice Address - Street 1:7170 N FINANCIAL DR STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2935
Practice Address - Country:US
Practice Address - Phone:559-492-8358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25297103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist