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NPI Code Detail

MEDICARE: JACK H BOOTH PSY.D, LPC

MEDICARE: JACK H BOOTH PSY.D, LPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor2674SC

General Provider Information

NPI Number : 1548291842
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK H BOOTH PSY.D, LPC
Provider Business Mailing Address
First Line : 709 OLD TROLLEY RD
Second Line :
City : SUMMERVILLE
State : SC
Zip : 29485-5203
Country : US
Telephone Number : 843-821-2480
Fax Number : 843-875-3149
Provider Business Practice Location Address
First Line : 709 OLD TROLLEY RD
Second Line :
City : SUMMERVILLE
State : SC
Zip : 29485-5203
Country : US
Telephone Number : 843-821-2480
Fax Number : 843-875-3149
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/05/2006
Last Update Date : 07/08/2007

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