MEDICARE: DR. JENNIFER A CHRYSTAN PH.D.

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	103TC0700X	Clinical Psychologist	7364547-250427	UT

General Provider Information

NPI Number	:	1982834800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER A CHRYSTAN PH.D.

Provider Business Mailing Address
First Line	:	2760 RASMUSSEN RD STE 205
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5685
Country	:	US
Telephone Number	:	801-688-3743
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 RASMUSSEN RD STE 205
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5685
Country	:	US
Telephone Number	:	801-688-3743
Fax Number	:

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

Provider Enumeration Date	:	07/27/2009
Last Update Date	:	07/27/2009

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