MEDICARE: JIMMY LAO

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	106H00000X	Marriage & Family Therapist	9818	ID
2	106H00000X	Marriage & Family Therapist	14222940-3904	UT

General Provider Information

NPI Number	:	1518701275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMY LAO

Provider Business Mailing Address
First Line	:	3725 W 4100 S STE 201
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-6490
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 S MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-3176
Country	:	US
Telephone Number	:	888-949-4864
Fax Number	:

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

Provider Enumeration Date	:	06/19/2024
Last Update Date	:	05/11/2026

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Directions to “ JIMMY LAO ” Practice Location

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