Healthcare Provider Details

I. General information

NPI: 1649040536
Provider Name (Legal Business Name): FIDDLE CREEK COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 N 300 W STE 16
KAYSVILLE UT
84037-3110
US

IV. Provider business mailing address

475 N 300 W STE 16
KAYSVILLE UT
84037-3110
US

V. Phone/Fax

Practice location:
  • Phone: 208-547-7762
  • Fax:
Mailing address:
  • Phone: 208-547-7762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JACLYN RANDOLPH
Title or Position: LCSW
Credential:
Phone: 208-547-7762