Healthcare Provider Details

I. General information

NPI: 1316153562
Provider Name (Legal Business Name): JARED MARK BOHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E 1300 N
LOGAN UT
84341
US

IV. Provider business mailing address

655 E 1300 N
LOGAN UT
84341
US

V. Phone/Fax

Practice location:
  • Phone: 435-792-6491
  • Fax: 435-792-6600
Mailing address:
  • Phone: 435-792-6491
  • Fax: 435-792-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5022459-3501
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: