Provider Demographics
NPI:1326677782
Name:TEN BOSCH, JIM CAREL
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:CAREL
Last Name:TEN BOSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35382 ROCA DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5460
Mailing Address - Country:US
Mailing Address - Phone:510-402-8489
Mailing Address - Fax:
Practice Address - Street 1:35382 ROCA DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5460
Practice Address - Country:US
Practice Address - Phone:510-402-8489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral