Healthcare Provider Details

I. General information

NPI: 1154400216
Provider Name (Legal Business Name): JERRY LYNN SANDBERG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 N MAIN ST STE B
BOUNTIFUL UT
84010-5996
US

IV. Provider business mailing address

1470 N MAIN ST STE B
BOUNTIFUL UT
84010-5996
US

V. Phone/Fax

Practice location:
  • Phone: 801-299-9026
  • Fax: 801-299-9026
Mailing address:
  • Phone: 801-299-9026
  • Fax: 801-299-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number117488-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: