Provider Demographics
NPI:1215153424
Name:BOYAN, JACK R (MED LMFT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:R
Last Name:BOYAN
Suffix:
Gender:M
Credentials:MED LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 BUFORD HWY NE
Mailing Address - Street 2:T-70
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2149
Mailing Address - Country:US
Mailing Address - Phone:404-315-7474
Mailing Address - Fax:404-982-0006
Practice Address - Street 1:2801 BUFORD HWY NE
Practice Address - Street 2:T-70
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2149
Practice Address - Country:US
Practice Address - Phone:404-315-7474
Practice Address - Fax:404-982-0006
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0599106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist