MEDICARE: MR. JEFFREY RALPH GRANT L.C.S.W.

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	123965-3501	UT

General Provider Information

NPI Number	:	1548329964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY RALPH GRANT L.C.S.W.

Provider Business Mailing Address
First Line	:	2860 LIVE OAK CIR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5544
Country	:	US
Telephone Number	:	801-277-0421
Fax Number	:	801-278-8504

Provider Business Practice Location Address
First Line	:	4190 HIGHLAND DR
Second Line	:	SUITE 210
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-274-0403
Fax Number	:

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

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

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