MEDICARE: JESSICA MERTLICH

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1649823162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MERTLICH

Provider Business Mailing Address
First Line	:	1564 E BARCON RD
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-7502
Country	:	US
Telephone Number	:	917-455-2427
Fax Number	:

Provider Business Practice Location Address
First Line	:	5681 S REDWOOD RD UNIT 24
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84123-5484
Country	:	US
Telephone Number	:	917-455-2427
Fax Number	:

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

Provider Enumeration Date	:	07/23/2019
Last Update Date	:	07/23/2019

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