Provider Demographics
NPI:1194860304
Name:GARDEN, JACK (HSPP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GARDEN
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7740 N 16TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4473
Mailing Address - Country:US
Mailing Address - Phone:802-274-5291
Mailing Address - Fax:
Practice Address - Street 1:7740 N 16TH ST STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4473
Practice Address - Country:US
Practice Address - Phone:802-274-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-004725103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN237590DDMedicare ID - Type Unspecified