Healthcare Provider Details

I. General information

NPI: 1538773387
Provider Name (Legal Business Name): JENNIFER ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7321 S STATE ST STE A
MIDVALE UT
84047-6105
US

IV. Provider business mailing address

1114 N ANTILLES DR
SALT LAKE CITY UT
84116-4656
US

V. Phone/Fax

Practice location:
  • Phone: 801-878-4327
  • Fax:
Mailing address:
  • Phone: 801-884-7359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13415058-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: