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General NPI Number Information
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NPI Number | 1689104309
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Entity Type | Individual
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Provider Name | JAN WIMMER L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 06/14/2017
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Provider Practice Location Address
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Address Line | 186 E 1800 N
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City | NORTH LOGAN
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State | UT
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Zip | 84341-2019
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Country | US
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Telephone | 435-770-1429
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Fax |
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Provider Business Mailing Address
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Address Line | 285 STONEHENGE DR
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City | PROVIDENCE
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State | UT
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Zip | 84332-9645
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Country | US
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Telephone | 435-770-1429
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 125403-6008
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 125403-3501
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License Number State | UT
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