Healthcare Provider Details

I. General information

NPI: 1356885552
Provider Name (Legal Business Name): JESSIE ROSDAHL MS, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7434 S STATE ST
MIDVALE UT
84047-2014
US

IV. Provider business mailing address

4001 S 300 E APT 11
SALT LAKE CITY UT
84107-1606
US

V. Phone/Fax

Practice location:
  • Phone: 801-456-9955
  • Fax:
Mailing address:
  • Phone: 801-822-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25435
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: