Healthcare Provider Details

I. General information

NPI: 1861815540
Provider Name (Legal Business Name): JENNIFER CORNETT BCBA, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 W SOUTH JORDAN PKWY STE 229
SOUTH JORDAN UT
84095-3979
US

IV. Provider business mailing address

489 W SOUTH JORDAN PKWY STE 229
SOUTH JORDAN UT
84095-3979
US

V. Phone/Fax

Practice location:
  • Phone: 385-220-7867
  • Fax: 385-900-1610
Mailing address:
  • Phone: 385-220-7867
  • Fax: 385-900-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7606069-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-13621
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: