MEDICARE: MR. JAROM GABRIEL GAITAN 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	8328725-6009	UT

General Provider Information

NPI Number	:	1558708966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAROM GABRIEL GAITAN CMHC

Provider Business Mailing Address
First Line	:	4460 S HIGHLAND DR
Second Line	:	SUITE 230
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3543
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	489 W SOUTH JORDAN PKWY STE 228
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-3980
Country	:	US
Telephone Number	:	801-341-9310
Fax Number	:

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

Provider Enumeration Date	:	05/24/2013
Last Update Date	:	06/15/2023

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