MEDICARE: JACQUELINE JENSEN TAYLOR

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1962111294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE JENSEN TAYLOR

Provider Business Mailing Address
First Line	:	1999 W NORTH TEMPLE APT B117
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-3977
Country	:	US
Telephone Number	:	801-864-4780
Fax Number	:

Provider Business Practice Location Address
First Line	:	1999 W NORTH TEMPLE APT B117
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-3977
Country	:	US
Telephone Number	:	801-864-4780
Fax Number	:

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

Provider Enumeration Date	:	11/15/2022
Last Update Date	:	11/15/2022

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