MEDICARE: AMANDA VAN LEEUWEN JENKS MFT INTERN

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

General Provider Information

NPI Number	:	1225763451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA VAN LEEUWEN JENKS MFT INTERN

Provider Business Mailing Address
First Line	:	274 N MAIN ST
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84321-3915
Country	:	US
Telephone Number	:	435-213-9278
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 W ANTELOPE DR STE 301
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-1156
Country	:	US
Telephone Number	:	435-213-9278
Fax Number	:

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

Provider Enumeration Date	:	07/21/2022
Last Update Date	:	07/21/2022

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