Healthcare Provider Details

I. General information

NPI: 1780731356
Provider Name (Legal Business Name): JANELLE IVERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 COMMERCE DR #250
MURRAY UT
84107-7926
US

IV. Provider business mailing address

5250 COMMERCE DR #250
MURRAY UT
84107-7926
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-3500
  • Fax: 801-261-2111
Mailing address:
  • Phone: 801-261-3500
  • Fax: 801-261-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5666631-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: