MEDICARE: JENNIFER ELIZABETH CMHC

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	101YP2500X	Professional Counselor	9656033-6004	UT

General Provider Information

NPI Number	:	1902368640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER ELIZABETH CMHC

Provider Business Mailing Address
First Line	:	1583 S 1600 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2829
Country	:	US
Telephone Number	:	801-636-3029
Fax Number	:

Provider Business Practice Location Address
First Line	:	1583 S 1600 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2829
Country	:	US
Telephone Number	:	801-636-3029
Fax Number	:

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

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	04/02/2019

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