MEDICARE: JENNY MARIAH THOMPSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	8571278-3501	UT

General Provider Information

NPI Number	:	1013342492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY MARIAH THOMPSON LCSW

Provider Business Mailing Address
First Line	:	1038 E FLORET LN APT 12P
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-4052
Country	:	US
Telephone Number	:	19-196-3448
Fax Number	:

Provider Business Practice Location Address
First Line	:	91 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-1531
Country	:	US
Telephone Number	:	801-569-1995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2013
Last Update Date	:	04/17/2023

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