Provider Demographics
NPI:1952329351
Name:BODEN, JOHN ELLIS (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ELLIS
Last Name:BODEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:ELLIS
Other - Last Name:BODEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 694
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-0694
Mailing Address - Country:US
Mailing Address - Phone:801-400-0734
Mailing Address - Fax:
Practice Address - Street 1:1258 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4711
Practice Address - Country:US
Practice Address - Phone:801-255-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5006522-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional