Healthcare Provider Details

I. General information

NPI: 1194860304
Provider Name (Legal Business Name): JACK GARDEN HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7740 N 16TH ST STE 300
PHOENIX AZ
85020-4473
US

IV. Provider business mailing address

7740 N 16TH ST STE 300
PHOENIX AZ
85020-4473
US

V. Phone/Fax

Practice location:
  • Phone: 802-274-5291
  • Fax:
Mailing address:
  • Phone: 802-274-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY-004725
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: