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General NPI Number Information
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NPI Number | 1841571353
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Entity Type | Individual
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Provider Name | JACOB EUGENE JACQUEZ LCSW
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Gender | Male
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Dates
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Enumeration Date | 08/30/2011
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 5814 S 900 E
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City | MURRAY
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State | UT
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Zip | 84121-1644
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Country | US
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Telephone | 385-800-3272
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Fax | 385-800-3260
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Provider Business Mailing Address
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Address Line | 5814 S 900 E
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City | MURRAY
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State | UT
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Zip | 84121-1644
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Country | US
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Telephone | 801-548-9696
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Fax | 385-800-3260
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-871
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License Number State | WY
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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 | 0904013199
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 4671239
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 7915180-3501
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License Number State | UT
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