Provider Demographics
NPI:1548534787
Name:DENDER, JACK MARK (MD, PSYD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MARK
Last Name:DENDER
Suffix:
Gender:M
Credentials:MD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1631 ALTA VISTA PL
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-4011
Mailing Address - Country:US
Mailing Address - Phone:818-606-8376
Mailing Address - Fax:805-482-8326
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE 919
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-606-8376
Practice Address - Fax:818-783-4403
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA345352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA034535OtherMEDICAL BOARD OF QUALITY ASSURANCE