=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275211963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DIAMOND LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2023
-----------------------------------------------------
Last Update Date | 08/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 826 N 100 E STE 1A
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-515-2282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2308 E 830 S UNIT 18
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-5402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-382-6572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 12654566-3902
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------