Provider Demographics
NPI:1447528567
Name:ROBINSON, JACK A (MA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 E PRAIRIE LN
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-5970
Mailing Address - Country:US
Mailing Address - Phone:602-717-8682
Mailing Address - Fax:928-649-0270
Practice Address - Street 1:4650 E PRAIRIE LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-5970
Practice Address - Country:US
Practice Address - Phone:602-717-8682
Practice Address - Fax:928-649-0270
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-03
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11096101YA0400X
AZLPC-11734101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)