Healthcare Provider Details

I. General information

NPI: 1598679193
Provider Name (Legal Business Name): JESSICA DAWN IRVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 S 1900 E
SALT LAKE CITY UT
84108-3143
US

IV. Provider business mailing address

2016 S 1900 E
SALT LAKE CITY UT
84108-3143
US

V. Phone/Fax

Practice location:
  • Phone: 208-971-7910
  • Fax:
Mailing address:
  • Phone: 208-971-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14223787-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: