MEDICARE: JEREMY AUSTIN CHILES PH.D.

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	376639-2501	UT

General Provider Information

NPI Number	:	1538486097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY AUSTIN CHILES PH.D.

Provider Business Mailing Address
First Line	:	1306 DEER CREST CIR
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-3204
Country	:	US
Telephone Number	:	801-643-2536
Fax Number	:	801-451-0539

Provider Business Practice Location Address
First Line	:	1306 DEER CREST CIR
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-3204
Country	:	US
Telephone Number	:	801-643-2536
Fax Number	:	801-451-0539

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

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	04/23/2010

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