MEDICARE: JANN DEWITT INC.

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	103TC0700X	Clinical Psychologist	308921-2501	UT

General Provider Information

NPI Number	:	1124327788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JANN DEWITT INC.

Provider Business Mailing Address
First Line	:	555 E 4500 S
Second Line	:	SUITE C150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-4533
Country	:	US
Telephone Number	:	801-288-0747
Fax Number	:

Provider Business Practice Location Address
First Line	:	1104 ASHTON AVE
Second Line	:	SUITE 108
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4504
Country	:	US
Telephone Number	:	801-510-4547
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARY JANN DEWITT
Credential	:	PHD
Telephone Number	:	801-510-4547

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/22/2011

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