Provider Demographics
NPI:1992850275
Name:BAKER, JACK W III (MS)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:W
Last Name:BAKER
Suffix:III
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1730 HIDDEN HOLLOW LN NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-1545
Mailing Address - Country:US
Mailing Address - Phone:319-393-5544
Mailing Address - Fax:319-743-0014
Practice Address - Street 1:1730 HIDDEN HOLLOW LN NW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-1545
Practice Address - Country:US
Practice Address - Phone:319-393-5544
Practice Address - Fax:319-743-0014
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA00259103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist