MEDICARE: JENI SCARLETT KOYLE CSW

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	11841804-3502	UT

General Provider Information

NPI Number	:	1679176028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENI SCARLETT KOYLE CSW

Provider Business Mailing Address
First Line	:	1578 W 1700 S STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-3461
Country	:	US
Telephone Number	:	801-972-2711
Fax Number	:	801-972-2709

Provider Business Practice Location Address
First Line	:	292 ODELL LN APT 4
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-4107
Country	:	US
Telephone Number	:	801-218-2951
Fax Number	:

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

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	11/18/2020

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