Healthcare Provider Details

I. General information

NPI: 1891754628
Provider Name (Legal Business Name): KORINA MAGDALENA JAGIELLO-CALDWELL CPCI
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 W 4700 S SUITE 1A
WEST VALLEY CITY UT
84118-2156
US

IV. Provider business mailing address

2880 W 4700 S SUITE 1A
WEST VALLEY CITY UT
84118-2156
US

V. Phone/Fax

Practice location:
  • Phone: 801-964-2465
  • Fax:
Mailing address:
  • Phone: 801-964-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4929649-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: