Healthcare Provider Details

I. General information

NPI: 1063480580
Provider Name (Legal Business Name): JEAN SODERQUIST PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

3557 ORCHARD HILLS WAY
WEST VALLEY CITY UT
84128-2472
US

V. Phone/Fax

Practice location:
  • Phone: 801-964-2465
  • Fax: 801-964-9075
Mailing address:
  • Phone: 801-252-1975
  • Fax: 801-964-9075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116830-3902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: