MEDICARE: DR. JACK MICHAEL BARBOUR M.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	2084P0800X	Psychiatry Physician	G40995	CA

General Provider Information

NPI Number	:	1568482792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK MICHAEL BARBOUR M.D.

Provider Business Mailing Address
First Line	:	2610 INDUSTRY WAY
Second Line	:	SUITE A
City	:	LYNWOOD
State	:	CA
Zip	:	90262-4028
Country	:	US
Telephone Number	:	310-631-8004
Fax Number	:	310-631-5875

Provider Business Practice Location Address
First Line	:	2610 INDUSTRY WAY
Second Line	:	SUITE A
City	:	LYNWOOD
State	:	CA
Zip	:	90262-4028
Country	:	US
Telephone Number	:	310-631-8004
Fax Number	:	310-631-5875

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	04/20/2015

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