MEDICARE: JESSICA LOUISE DECKER 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	172V00000X	Community Health Worker
2	101YM0800X	Mental Health Counselor	9418686-6004	UT

General Provider Information

NPI Number	:	1730512765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LOUISE DECKER CMHC

Provider Business Mailing Address
First Line	:	1743 LAURELWOOD DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-4952
Country	:	US
Telephone Number	:	650-248-4855
Fax Number	:

Provider Business Practice Location Address
First Line	:	4943 S WASATCH BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-4798
Country	:	US
Telephone Number	:	385-202-5868
Fax Number	:

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

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	01/05/2022

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