Provider Demographics
NPI:1548291842
Name:BOOTH, JACK H (PSYD, LPC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:H
Last Name:BOOTH
Suffix:
Gender:M
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 OLD TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5203
Mailing Address - Country:US
Mailing Address - Phone:843-821-2480
Mailing Address - Fax:843-875-3149
Practice Address - Street 1:709 OLD TROLLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5203
Practice Address - Country:US
Practice Address - Phone:843-821-2480
Practice Address - Fax:843-875-3149
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2674101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health