Active NPI
Jack S. Tanenbaum, LCSW
- Mental Health Counselor
- Lodi, CA
National Provider Identifier
1154419505
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- LCS 1098
- Practice address
- 1920 Tienda Dr
Ste 101
Lodi, CA 95242-3930 - Phone
- (916) 662-5947
- Fax
- (209) 366-1133
- NPI assigned
- Oct 11, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | LCS 1098 | CA | Primary |
Addresses
Primary practice location
1920 Tienda Dr
Ste 101
Lodi, CA 95242-3930
Mailing address
2715 W Kettleman LN
Ste 203-113
Lodi, CA 95242-9289
Phone (916) 662-5947
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100803000661 | CA | Practitioner - Clinical Social Worker | 9537292115 | Practice locations: Lodi, CA |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Social Worker
- Education
- New York University School of Medicine, 1964
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
Practice addresses (Care Compare)
1209 W Tokay St
Suite 11
Lodi, CA 95240-3845
Phone (916) 662-5947
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LCS 1098 | CA | MD | Mental Health Counselor |
| 1098 | CA | MD | Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1160524800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1285891200000",
"number": "1154419505",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2715 W KETTLEMAN LN",
"address_2": "STE 203-113",
"city": "LODI",
"state": "CA",
"postal_code": "952429289",
"telephone_number": "916-662-5947",
"fax_number": "209-366-1133"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1920 TIENDA DR",
"address_2": "STE 101",
"city": "LODI",
"state": "CA",
"postal_code": "952423930",
"telephone_number": "916-662-5947",
"fax_number": "209-366-1133"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TANENBAUM",
"first_name": "JACK",
"middle_name": "S.",
"name_prefix": "Mr.",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-11",
"last_updated": "2010-10-01",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "CA",
"license": "LCS 1098",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lodi, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.