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General NPI Number Information
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NPI Number | 1053133322
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Entity Type | Organization
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Legal Business Name | SIDELINE SPORT PSYCHOLOGY PLLC
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Dates
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Enumeration Date | 10/29/2024
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 1336 S 1100 E
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City | SALT LAKE CITY
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State | UT
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Zip | 84105-2421
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Country | US
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Telephone | 385-899-2251
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Fax |
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Provider Business Mailing Address
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Address Line | 4715 S BRON BRECK ST
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City | HOLLADAY
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State | UT
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Zip | 84117-6403
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Country | US
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Telephone | 916-690-6482
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOURDAN JOHNSON
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Credential | EDD, LMFT, CMPC
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Telephone | 916-690-0399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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