Healthcare Provider Details

I. General information

NPI: 1659491520
Provider Name (Legal Business Name): ELISABETH K. JOLLEY MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 E 3900 S 102
SALT LAKE CITY UT
84107-1550
US

IV. Provider business mailing address

9770 DANTE CIR
SANDY UT
84092-4272
US

V. Phone/Fax

Practice location:
  • Phone: 801-943-1981
  • Fax:
Mailing address:
  • Phone: 801-943-1981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number90-1372353501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: