Healthcare Provider Details

I. General information

NPI: 1225134893
Provider Name (Legal Business Name): JACK SAUL WASSERMAN PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 DOVE ST
NEWPORT BEACH CA
92660-2839
US

IV. Provider business mailing address

1101 DOVE ST
NEWPORT BEACH CA
92660-2839
US

V. Phone/Fax

Practice location:
  • Phone: 714-812-6869
  • Fax:
Mailing address:
  • Phone: 714-812-6869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY11898
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: