Provider Demographics
NPI:1891852794
Name:WEITZMAN, JACK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:WEITZMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4824
Mailing Address - Country:US
Mailing Address - Phone:408-396-6191
Mailing Address - Fax:408-972-6494
Practice Address - Street 1:1215 FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4824
Practice Address - Country:US
Practice Address - Phone:408-396-6191
Practice Address - Fax:408-972-6494
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALN0092941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAM599482Medicare UPIN