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NPI Code Detail

MEDICARE: JAN WIMMER L.C.S.W.

MEDICARE: JAN WIMMER 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
1101YA0400XAddiction (Substance Use Disorder) Counselor125403-6008UT
21041C0700XClinical Social Worker125403-3501UT

General Provider Information

NPI Number : 1689104309
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAN WIMMER L.C.S.W.
Provider Business Mailing Address
First Line : 285 STONEHENGE DR
Second Line :
City : PROVIDENCE
State : UT
Zip : 84332-9645
Country : US
Telephone Number : 435-770-1429
Fax Number :
Provider Business Practice Location Address
First Line : 186 E 1800 N
Second Line :
City : NORTH LOGAN
State : UT
Zip : 84341-2019
Country : US
Telephone Number : 435-770-1429
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2017
Last Update Date : 06/14/2017

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