=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346180692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON WILLIAM FUNK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2026
-----------------------------------------------------
Last Update Date | 03/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2450 E FORT UNION BLVD
-----------------------------------------------------
City | COTTONWOOD HEIGHTS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-3337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-669-5888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7692 S AVONDALE DR
-----------------------------------------------------
City | COTTONWOOD HEIGHTS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-5507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-760-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 14226532-3502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------