MEDICARE: JESSICA WACKER

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	101YM0800X	Mental Health Counselor	7727205-6004	UT

General Provider Information

NPI Number	:	1083737480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA WACKER

Provider Business Mailing Address
First Line	:	1782 HOLLADAY BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2606
Country	:	US
Telephone Number	:	801-703-5321
Fax Number	:

Provider Business Practice Location Address
First Line	:	1782 HOLLADAY BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2606
Country	:	US
Telephone Number	:	801-703-5321
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	01/12/2012

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Directions to “ JESSICA WACKER ” Practice Location

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