Healthcare Provider Details

I. General information

NPI: 1821348640
Provider Name (Legal Business Name): FABIOLA MARQUEZ JAMIESON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S 2180 E SUITE 165
HOLLADAY UT
84117
US

IV. Provider business mailing address

823 2ND AVE APT B
SALT LAKE CITY UT
84103
US

V. Phone/Fax

Practice location:
  • Phone: 801-461-9060
  • Fax:
Mailing address:
  • Phone: 801-360-5191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73763963501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: