Healthcare Provider Details

I. General information

NPI: 1740545672
Provider Name (Legal Business Name): JEREMY DAVID FOOTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5965 S 900 E
SALT LAKE CITY UT
84121-1720
US

IV. Provider business mailing address

5965 S 900 E
SALT LAKE CITY UT
84121-1720
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-7138
  • Fax:
Mailing address:
  • Phone: 801-263-7138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9484273-3501
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: