MEDICARE: DR. JAN ELLEN KADERABEK BURTON PH.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	1103862501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107009442101	OTHER	UT	INTERMOUNTAIN HEALTH CARE
2	261736	OTHER	UT	DESERET MUTUAL
3	942938348BU1	OTHER	UT	EDUCATORS MUTUAL

General Provider Information

NPI Number	:	1578506697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAN ELLEN KADERABEK BURTON PH.D.

Provider Business Mailing Address
First Line	:	4190 HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-274-0403
Fax Number	:

Provider Business Practice Location Address
First Line	:	4190 HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-274-0403
Fax Number	:

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/09/2007

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