Provider Demographics
NPI:1144334269
Name:JAFFE, JACK (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:JAFFE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7422 FOXWORTH DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3038
Mailing Address - Country:US
Mailing Address - Phone:972-693-5485
Mailing Address - Fax:
Practice Address - Street 1:6330 LYNDON B JOHNSON FWY STE 130
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6443
Practice Address - Country:US
Practice Address - Phone:972-693-5485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149708301Medicaid
TX86707AOtherBLUE CROSS BLUE SHIELD
TX86707AOtherBLUE CROSS BLUE SHIELD