Provider Demographics
NPI:1366477325
Name:TALLMAN, JACK WARD (MFT/DAPA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:WARD
Last Name:TALLMAN
Suffix:
Gender:M
Credentials:MFT/DAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17772 IRVINE BLVD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3256
Mailing Address - Country:US
Mailing Address - Phone:714-836-1101
Mailing Address - Fax:714-730-6670
Practice Address - Street 1:17772 IRVINE BLVD
Practice Address - Street 2:SUITE #101
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3256
Practice Address - Country:US
Practice Address - Phone:714-836-1101
Practice Address - Fax:714-730-6670
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC24161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist