Provider Demographics
NPI:1811394364
Name:REID, JACK (PCCI #1189)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:REID
Suffix:
Gender:M
Credentials:PCCI #1189
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PCCI #1189
Mailing Address - Street 1:110 GOUGH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5945
Mailing Address - Country:US
Mailing Address - Phone:415-944-3628
Mailing Address - Fax:
Practice Address - Street 1:110 GOUGH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-5945
Practice Address - Country:US
Practice Address - Phone:415-944-3628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-28
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI 1189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health