=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053819938
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY JANE BENNETT CSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2018
-----------------------------------------------------
Last Update Date | 09/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 267 E TRAVERSEPOINT DR
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-5679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-824-1328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2587 E OAK CREEK CIR
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84093-6526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-824-1328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------