Provider Demographics
NPI:1972671899
Name:FARMER, JACK LEE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEE
Last Name:FARMER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1202 MORENA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3841
Mailing Address - Country:US
Mailing Address - Phone:619-275-0822
Mailing Address - Fax:619-275-1422
Practice Address - Street 1:1202 MORENA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3841
Practice Address - Country:US
Practice Address - Phone:619-275-0822
Practice Address - Fax:619-275-1422
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16037103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical