Healthcare Provider Details

I. General information

NPI: 1346773504
Provider Name (Legal Business Name): JACK VANBEZOOYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JACK VAN BEZOOYEN

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 TAMAL VISTA BLVD
CORTE MADERA CA
94925-1132
US

IV. Provider business mailing address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 916-969-7074
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number171751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: