Healthcare Provider Details

I. General information

NPI: 1912405259
Provider Name (Legal Business Name): CORTNEY JADE CARGEEG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E GORDON AVE
LAYTON UT
84041-2341
US

IV. Provider business mailing address

209 E GORDON AVE
LAYTON UT
84041-2341
US

V. Phone/Fax

Practice location:
  • Phone: 801-200-1574
  • Fax:
Mailing address:
  • Phone: 12-001-5748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49623
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: