MEDICARE: JACOB EUGENE JACQUEZ 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	LCSW-871	WY
2	1041C0700X	Clinical Social Worker	0904013199	VA
3	1041C0700X	Clinical Social Worker	4671239	ID
4	1041C0700X	Clinical Social Worker	7915180-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841571353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB EUGENE JACQUEZ LCSW

Provider Business Mailing Address
First Line	:	5814 S 900 E
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-1644
Country	:	US
Telephone Number	:	801-548-9696
Fax Number	:	385-800-3260

Provider Business Practice Location Address
First Line	:	5814 S 900 E
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-1644
Country	:	US
Telephone Number	:	385-800-3272
Fax Number	:	385-800-3260

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

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	12/06/2024

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