Provider Demographics
NPI:1508947706
Name:BOHANON, JACK ROY (MFT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ROY
Last Name:BOHANON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:123 GLADYS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-3967
Mailing Address - Country:US
Mailing Address - Phone:650-599-2262
Mailing Address - Fax:650-625-1551
Practice Address - Street 1:703 WELCH RD
Practice Address - Street 2:STE. F6
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1710
Practice Address - Country:US
Practice Address - Phone:650-599-2262
Practice Address - Fax:650-625-1551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29822101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist