MEDICARE: DR. JESSE GORA PSY.D.

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	103TC0700X	Clinical Psychologist	50251392501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107029545101	OTHER	UT	U006
2	8573690	OTHER	UT	U002
3	942938348015	OTHER	UT	U009
4	Q11013	OTHER	UT	ICAR

General Provider Information

NPI Number	:	1386629376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE GORA PSY.D.

Provider Business Mailing Address
First Line	:	4659 BROOKWOOD DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4909
Country	:	US
Telephone Number	:	801-532-7414
Fax Number	:

Provider Business Practice Location Address
First Line	:	1060 E 100 S
Second Line	:	SUITE 105
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1501
Country	:	US
Telephone Number	:	801-532-7414
Fax Number	:

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

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	10/18/2007

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