MEDICARE: JACOB GRANT BROWN 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	10540388-6004	UT
2	101YM0800X	Mental Health Counselor	LAC-16935	AZ

General Provider Information

NPI Number	:	1962912501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB GRANT BROWN CMHC

Provider Business Mailing Address
First Line	:	3725 W 4100 S STE 201
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-6490
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 S MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-3176
Country	:	US
Telephone Number	:	888-949-4864
Fax Number	:

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

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	04/10/2026

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