Healthcare Provider Details

I. General information

NPI: 1396163002
Provider Name (Legal Business Name): JESSICA OTIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12971 S SHAWNEE DR
RIVERTON UT
84096-7805
US

IV. Provider business mailing address

12971 S SHAWNEE DR
RIVERTON UT
84096-7805
US

V. Phone/Fax

Practice location:
  • Phone: 801-910-5587
  • Fax:
Mailing address:
  • Phone: 801-910-5587
  • Fax: 801-206-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-925
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113051
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-36030
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8696808-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: