Healthcare Provider Details

I. General information

NPI: 1023103926
Provider Name (Legal Business Name): JARED M. TAYLOR LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W 1400 N SUITE A
LOGAN UT
84341-6811
US

IV. Provider business mailing address

PO BOX 557
MILLVILLE UT
84326-0557
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-5302
  • Fax: 435-753-9007
Mailing address:
  • Phone: 435-752-5302
  • Fax: 435-753-9007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 6201971-3501
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: