Provider Demographics
NPI:1720176019
Name:LAFORTE, JACK T (PHD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:LAFORTE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3000
Mailing Address - Country:US
Mailing Address - Phone:413-586-6100
Mailing Address - Fax:413-586-3332
Practice Address - Street 1:53 CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3000
Practice Address - Country:US
Practice Address - Phone:413-586-6100
Practice Address - Fax:413-586-3332
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4323103T00000X
MA33106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA33OtherLMFT LICENSE
MA799131OtherTUFTS HEALTH PLAN PROVIDE
MA84244110OtherUBH ONLINE ID
MA4323OtherPSYCHOLOGISTS LICENSE
MA004556OtherVALUE OPTIONS
MA33OtherLMFT LICENSE