Healthcare Provider Details

I. General information

NPI: 1841616224
Provider Name (Legal Business Name): HOLLEY JEPPSON CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11717 S AMBER STONE DR
SOUTH JORDAN UT
84095-8076
US

IV. Provider business mailing address

11717 S AMBER STONE DR
SOUTH JORDAN UT
84095-8076
US

V. Phone/Fax

Practice location:
  • Phone: 801-574-5683
  • Fax: 385-234-4822
Mailing address:
  • Phone: 801-574-5683
  • Fax: 385-234-4822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8160113-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: