Provider Demographics
NPI:1154419505
Name:TANENBAUM, JACK S (LCSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:S
Last Name:TANENBAUM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 W KETTLEMAN LN
Mailing Address - Street 2:STE 203-113
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9289
Mailing Address - Country:US
Mailing Address - Phone:916-662-5947
Mailing Address - Fax:209-366-1133
Practice Address - Street 1:1920 TIENDA DR
Practice Address - Street 2:STE 101
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3930
Practice Address - Country:US
Practice Address - Phone:916-662-5947
Practice Address - Fax:209-366-1133
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 1098101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health