Provider Demographics
NPI:1760245369
Name:KLITZNER, JACK WYATT
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WYATT
Last Name:KLITZNER
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 1:26 KIRKBRAE DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1019
Mailing Address - Country:US
Mailing Address - Phone:401-556-8346
Mailing Address - Fax:
Practice Address - Street 1:33 PERRY AVE
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2417
Practice Address - Country:US
Practice Address - Phone:508-403-6109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician