Healthcare Provider Details

I. General information

NPI: 1821515420
Provider Name (Legal Business Name): JESSICA WALTERS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 N MAIN ST STE 6
BOUNTIFUL UT
84010-5982
US

IV. Provider business mailing address

3413 W 1340 N
CLINTON UT
84015-7531
US

V. Phone/Fax

Practice location:
  • Phone: 801-513-1727
  • Fax:
Mailing address:
  • Phone: 435-512-1791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12890360-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: