Healthcare Provider Details

I. General information

NPI: 1649838863
Provider Name (Legal Business Name): JERICHO BRENT AVERY CSW, CSUDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 E 100 N
AMERICAN FORK UT
84003-1651
US

IV. Provider business mailing address

2214 E LOCH LOMOND DR
SARATOGA SPRINGS UT
84043-3911
US

V. Phone/Fax

Practice location:
  • Phone: 385-374-9708
  • Fax:
Mailing address:
  • Phone: 385-374-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10395960-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: