=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205305117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENISABEL S PYZIKIEWICZ LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2018
-----------------------------------------------------
Last Update Date | 08/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10782 S OZARKS DR
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84009-5693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-820-3047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10782 S OZARKS DR
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84009-5693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-820-3047
-----------------------------------------------------
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 | 097800
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 11339443-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------