Provider Demographics
NPI:1760597769
Name:FRENCH, JACK TODT JR (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:TODT
Last Name:FRENCH
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1114 6TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2203
Practice Address - Country:US
Practice Address - Phone:209-576-2845
Practice Address - Fax:209-576-8842
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104660Medicaid
CARHM53830HMedicaid
P13597Medicare UPIN
CAZZZ04426ZMedicare ID - Type UnspecifiedGROUP MEDICARE ID
CAGR0104660Medicaid