MEDICARE: MRS. JAN MARIE MALMBERG LPC

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	101YP2500X	Professional Counselor	4905206-6004	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11627987	OTHER	UT	CAQH

General Provider Information

NPI Number	:	1225193998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAN MARIE MALMBERG LPC

Provider Business Mailing Address
First Line	:	2223 AROSA CIR
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1039
Country	:	US
Telephone Number	:	801-943-5061
Fax Number	:

Provider Business Practice Location Address
First Line	:	4214 S 500 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84123-1336
Country	:	US
Telephone Number	:	801-859-3523
Fax Number	:

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

Provider Enumeration Date	:	12/23/2006
Last Update Date	:	07/08/2007

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