Healthcare Provider Details

I. General information

NPI: 1922394220
Provider Name (Legal Business Name): JEREMY J DAVIS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E 1R55
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E 1R55
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2932
  • Fax:
Mailing address:
  • Phone: 801-581-2932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number8081803-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: