MEDICARE: MS. SIMONE JASMIN HENNIG LCSW

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	139503-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	139503-3501	OTHER	UT	UTAH STATE LICENSE

General Provider Information

NPI Number	:	1780887521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SIMONE JASMIN HENNIG LCSW

Provider Business Mailing Address
First Line	:	451 BISHOP FEDERAL LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2357
Country	:	US
Telephone Number	:	801-468-6856
Fax Number	:	801-487-1112

Provider Business Practice Location Address
First Line	:	451 BISHOP FEDERAL LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2357
Country	:	US
Telephone Number	:	801-468-6856
Fax Number	:	801-487-1112

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	06/22/2021

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