Healthcare Provider Details

I. General information

NPI: 1164469508
Provider Name (Legal Business Name): RYAN LARRY JEFFS MS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 WEST 1350 SOUTH
WOODS CROSS UT
84087
US

IV. Provider business mailing address

13628 SOUTH PREMIER LANE
HERRIMAN UT
84065-1702
US

V. Phone/Fax

Practice location:
  • Phone: 801-299-5360
  • Fax:
Mailing address:
  • Phone: 801-446-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number56962563902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: