Healthcare Provider Details

I. General information

NPI: 1629693122
Provider Name (Legal Business Name): JARED BLAINE TWITCHELL ACMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12397 S 300 E STE 100
DRAPER UT
84020-8274
US

IV. Provider business mailing address

1491 E CENTER ST
SPRINGVILLE UT
84663-2140
US

V. Phone/Fax

Practice location:
  • Phone: 385-900-4020
  • Fax: 801-790-0139
Mailing address:
  • Phone: 480-432-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number311580-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6881828
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: