Provider Demographics
NPI:1346855053
Name:SAMATH, JACK ETHAN
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ETHAN
Last Name:SAMATH
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 1:237 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2601
Mailing Address - Country:US
Mailing Address - Phone:408-386-4147
Mailing Address - Fax:
Practice Address - Street 1:8616 LA TIJERA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3944
Practice Address - Country:US
Practice Address - Phone:805-490-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-24-75204103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst