MEDICARE: JODI LYN BLACK CMHC

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	101YM0800X	Mental Health Counselor	3504286004	UT

General Provider Information

NPI Number	:	1033691258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI LYN BLACK CMHC

Provider Business Mailing Address
First Line	:	184 E PARADISE CT
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-4504
Country	:	US
Telephone Number	:	801-678-3971
Fax Number	:

Provider Business Practice Location Address
First Line	:	184 E PARADISE CT
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-4504
Country	:	US
Telephone Number	:	801-678-3971
Fax Number	:

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

Provider Enumeration Date	:	09/04/2018
Last Update Date	:	09/20/2022

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