Healthcare Provider Details

I. General information

NPI: 1023680386
Provider Name (Legal Business Name): UTAH INTEGRATIVE PSYCHIATRY & ADDICTION MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 308
PROVO UT
84604-3373
US

IV. Provider business mailing address

1055 N 300 W STE 308
PROVO UT
84604-3373
US

V. Phone/Fax

Practice location:
  • Phone: 801-921-0031
  • Fax: 801-210-5812
Mailing address:
  • Phone: 801-921-0031
  • Fax: 801-210-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON LEE ANDERSEN
Title or Position: OWNER
Credential:
Phone: 801-921-0031