Healthcare Provider Details

I. General information

NPI: 1366391609
Provider Name (Legal Business Name): BOBBIE GENE SIMMONS SUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2026
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 S 1300 W
WEST JORDAN UT
84088-9201
US

IV. Provider business mailing address

8901 S 1300 W
WEST JORDAN UT
84088-9201
US

V. Phone/Fax

Practice location:
  • Phone: 801-816-4977
  • Fax:
Mailing address:
  • Phone: 801-816-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: