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General NPI Number Information
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NPI Number | 1851822464
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Entity Type | Individual
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Provider Name | JESSICA LACEY FISHER CHAMPLIN L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 03/24/2017
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Last Update Date | 06/06/2023
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Provider Practice Location Address
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Address Line | 1290 S 500 W STE 300
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City | WOODS CROSS
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State | UT
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Zip | 84010-8104
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Country | US
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Telephone | 801-215-9575
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Fax | 833-904-1668
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Provider Business Mailing Address
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Address Line | 553 N 190 E
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City | NORTH SALT LAKE
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State | UT
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Zip | 84054-2200
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Country | US
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Telephone | 801-215-9575
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Fax | 833-904-1668
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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 | 10853410-3501
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License Number State | UT
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