MEDICARE: JANE WOOLLAM BEBB LCSW

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	1041C0700X	Clinical Social Worker	112994-3501	UT

General Provider Information

NPI Number	:	1518177633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE WOOLLAM BEBB LCSW

Provider Business Mailing Address
First Line	:	4709 WALLACE LN
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-6408
Country	:	US
Telephone Number	:	801-278-1138
Fax Number	:

Provider Business Practice Location Address
First Line	:	4709 WALLACE LN
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-6408
Country	:	US
Telephone Number	:	801-278-1138
Fax Number	:

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	07/08/2007

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