MEDICARE: JAISHA REBECCA SEGO

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1174172290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAISHA REBECCA SEGO

Provider Business Mailing Address
First Line	:	1849 N FREEDOM BLVD APT 138
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-1527
Country	:	US
Telephone Number	:	385-404-9334
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 W. 1130 S.
Second Line	:	BUILDING B
City	:	OREM
State	:	UT
Zip	:	84058-2888
Country	:	US
Telephone Number	:	801-935-4171
Fax Number	:	801-935-4946

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

Provider Enumeration Date	:	09/11/2019
Last Update Date	:	09/11/2019

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