MEDICARE: DR. JACK SAUL WASSERMAN PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	PSY11898	CA
2	103TC0700X	Clinical Psychologist	11898	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225134893	OTHER	CA	103TA0400X

General Provider Information

NPI Number	:	1225134893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK SAUL WASSERMAN PH.D

Provider Business Mailing Address
First Line	:	1101 DOVE ST
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2839
Country	:	US
Telephone Number	:	714-812-6869
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 DOVE ST
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2839
Country	:	US
Telephone Number	:	714-812-6869
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	01/22/2019

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