Provider Demographics
NPI:1427081942
Name:WITZ, JACK ROBERT (LAC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ROBERT
Last Name:WITZ
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 1:5409 KATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4922
Mailing Address - Country:US
Mailing Address - Phone:626-644-7510
Mailing Address - Fax:
Practice Address - Street 1:12626 RIVERSIDE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3420
Practice Address - Country:US
Practice Address - Phone:626-644-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8398171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist