Healthcare Provider Details

I. General information

NPI: 1407153547
Provider Name (Legal Business Name): JENNIFER POULOS LCSW, LSUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 S LEGEND HILLS DR STE 334
CLEARFIELD UT
84015-1592
US

IV. Provider business mailing address

131 E 2600 S
CLEARFIELD UT
84015-1951
US

V. Phone/Fax

Practice location:
  • Phone: 801-608-9966
  • Fax:
Mailing address:
  • Phone: 801-608-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8139526-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8139526-6006
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8139526-3506
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: