Provider Demographics
NPI:1740827989
Name:LE, JACK
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:LE
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 1:9901 WILLIAM DALTON WAY
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-3843
Mailing Address - Country:US
Mailing Address - Phone:714-468-9961
Mailing Address - Fax:
Practice Address - Street 1:701 W KIMBERLY AVE STE 245
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6345
Practice Address - Country:US
Practice Address - Phone:714-780-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician