Provider Demographics
NPI:1083067896
Name:BOYCE, JAZ CICERO SANTANA
Entity Type:Individual
Prefix:
First Name:JAZ
Middle Name:CICERO SANTANA
Last Name:BOYCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EIJAZ
Other - Middle Name:KAYTENNAE
Other - Last Name:SHABAZZ EL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3118 HOUSTON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-3398
Mailing Address - Country:US
Mailing Address - Phone:614-407-6352
Mailing Address - Fax:
Practice Address - Street 1:3118 HOUSTON DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-3398
Practice Address - Country:US
Practice Address - Phone:614-407-6352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-16
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children