Healthcare Provider Details

I. General information

NPI: 1083393755
Provider Name (Legal Business Name): JACLYN BOGNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ATHENS WAY STE 320
NASHVILLE TN
37228-1311
US

IV. Provider business mailing address

220 ATHENS WAY STE 104
NASHVILLE TN
37228-1351
US

V. Phone/Fax

Practice location:
  • Phone: 615-320-1155
  • Fax: 615-320-1177
Mailing address:
  • Phone: 615-320-1155
  • Fax: 615-320-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4241
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: