Provider Demographics
NPI:1780371401
Name:WEBER, JACK (LAC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:WEBER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93024-1085
Mailing Address - Country:US
Mailing Address - Phone:808-938-2405
Mailing Address - Fax:
Practice Address - Street 1:578 EL SOL ST
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-3538
Practice Address - Country:US
Practice Address - Phone:808-938-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7366171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist