Provider Demographics
NPI:1104994318
Name:BOGGS, JAN C (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:C
Last Name:BOGGS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GROVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-1812
Mailing Address - Country:US
Mailing Address - Phone:260-249-8429
Mailing Address - Fax:260-244-1983
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 285
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:260-422-0843
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1041C0700X
IN34000520A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200532500AMedicaid
IN200532500AMedicaid