Provider Demographics
NPI:1912145079
Name:FELTON, JACK A (MFT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:A
Last Name:FELTON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:A
Other - Last Name:FELTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:3140 RED HILL AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3400
Mailing Address - Country:US
Mailing Address - Phone:714-546-6806
Mailing Address - Fax:714-546-6063
Practice Address - Street 1:3140 RED HILL AVE STE 130
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3400
Practice Address - Country:US
Practice Address - Phone:714-546-6806
Practice Address - Fax:714-546-6063
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT29020106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT29020OtherSTATE OF CALIFORNIA