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General NPI Number Information
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NPI Number | 1366477325
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Entity Type | Individual
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Provider Name | JACK WARD TALLMAN MFT/DAPA
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Gender | Male
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Dates
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Enumeration Date | 07/11/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 17772 IRVINE BLVD SUITE #101
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City | TUSTIN
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State | CA
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Zip | 92780-3256
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Country | US
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Telephone | 714-836-1101
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Fax | 714-730-6670
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Provider Business Mailing Address
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Address Line | 17772 IRVINE BLVD SUITE #101
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City | TUSTIN
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State | CA
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Zip | 92780-3256
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Country | US
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Telephone | 714-836-1101
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Fax | 714-730-6670
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC24161
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License Number State | CA
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