Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY8154 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY8154 | CA |
NPI | 1013113091 |
---|---|
Provider Name | Dr. Jack Boghosian |
First Address | West Covina, CA 91790-2703 |
Second Address | West Covina, CA 91790-2703 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2007 |
Last Update Date | 08/07/2007 |