Provider Demographics
NPI:1447459680
Name:ANCHIN, JACK CHARLES (PHD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:CHARLES
Last Name:ANCHIN
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 1:4444 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SNYDER
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4420
Mailing Address - Country:US
Mailing Address - Phone:716-839-1299
Mailing Address - Fax:
Practice Address - Street 1:4444 MAIN ST
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:NY
Practice Address - Zip Code:14226-4420
Practice Address - Country:US
Practice Address - Phone:716-839-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007199-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000500095003OtherBLUE CROSS AND BLUE SHIEL
NY000500095003OtherBLUE CROSS AND BLUE SHIEL