=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932747169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALEY JEX
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 377 MARSHALL WAY STE 1
-----------------------------------------------------
City | LAYTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84041-7378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-725-2008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6039 W 5150 S
-----------------------------------------------------
City | HOOPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84315-6742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-725-2008
-----------------------------------------------------
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 | 11269431-3502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------