Healthcare Provider Details

I. General information

NPI: 1659314201
Provider Name (Legal Business Name): JASON A HALES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 N MAIN ST 12
TOOELE UT
84074-2100
US

IV. Provider business mailing address

65 N MAIN ST UNIT 667
TOOELE UT
84074-2217
US

V. Phone/Fax

Practice location:
  • Phone: 801-783-9265
  • Fax:
Mailing address:
  • Phone: 801-783-9265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4979280-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier219792803501001
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerBCBS ID # INDIVIDUAL
# 2
IdentifierB0930
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: