Healthcare Provider Details

I. General information

NPI: 1417025040
Provider Name (Legal Business Name): JESSE KATHERINE VAZZANO LICSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA SALT LAKE CITY HEALTH CARE SYSTEM 500 FOOTHILL BLVD
SALT LAKE CITY UT
84148
US

IV. Provider business mailing address

VA SALT LAKE CITY HEALTH CARE SYSTEM 500 FOOTHILL BLVD
SALT LAKE CITY UT
84148
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-582-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0046104
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14228253-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: