Healthcare Provider Details

I. General information

NPI: 1740686252
Provider Name (Legal Business Name): BRIDGING RESILIENCE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 E 2100 S STE 101
SALT LAKE CITY UT
84106-1863
US

IV. Provider business mailing address

774 E 2100 S STE 101
SALT LAKE CITY UT
84106-1863
US

V. Phone/Fax

Practice location:
  • Phone: 801-842-9317
  • Fax:
Mailing address:
  • Phone: 801-842-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACOB EUGENE JACQUEZ
Title or Position: OWNER
Credential: LCSW
Phone: 801-842-9317