Healthcare Provider Details

I. General information

NPI: 1750859997
Provider Name (Legal Business Name): JERICHO C PINEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1576 S 500 W
BOUNTIFUL UT
84010-7433
US

IV. Provider business mailing address

1576 S 500 W
WOODS CROSS UT
84010-7433
US

V. Phone/Fax

Practice location:
  • Phone: 801-406-9002
  • Fax: 801-855-5660
Mailing address:
  • Phone: 801-406-9002
  • Fax: 801-855-5660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10998714-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: