Provider Demographics
NPI:1891559548
Name:DANFORTH, JACK RAMSDELL
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:RAMSDELL
Last Name:DANFORTH
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 1:1055 N PARK AVE UNIT 322
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-4430
Mailing Address - Country:US
Mailing Address - Phone:760-396-7682
Mailing Address - Fax:
Practice Address - Street 1:1517 HIGHWAY 13 E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2917
Practice Address - Country:US
Practice Address - Phone:612-756-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-21
Deactivation Date:2024-02-13
Deactivation Code:
Reactivation Date:2024-02-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health