Healthcare Provider Details

I. General information

NPI: 1952329351
Provider Name (Legal Business Name): JOHN ELLIS BODEN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK ELLIS BODEN LPC

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 W SOUTH JORDAN PKWY SUITE 202
SOUTH JORDAN UT
84095-4711
US

IV. Provider business mailing address

PO BOX 694
AMERICAN FORK UT
84003-0694
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-1155
  • Fax:
Mailing address:
  • Phone: 801-400-0734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5006522-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: