MEDICARE: JEAN SODERQUIST PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	116830-3902	UT

General Provider Information

NPI Number	:	1063480580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN SODERQUIST PH.D.

Provider Business Mailing Address
First Line	:	3557 ORCHARD HILLS WAY
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84128-2472
Country	:	US
Telephone Number	:	801-252-1975
Fax Number	:	801-964-9075

Provider Business Practice Location Address
First Line	:	2880 W 4700 S
Second Line	:	SUITE A
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84118-2156
Country	:	US
Telephone Number	:	801-964-2465
Fax Number	:	801-964-9075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	07/08/2007

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Directions to “ JEAN SODERQUIST PH.D.” Practice Location

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