Provider Demographics
NPI:1033754338
Name:OSTLER, JACOB EUGENE
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:EUGENE
Last Name:OSTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 S GARY RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2311
Mailing Address - Country:US
Mailing Address - Phone:801-554-2336
Mailing Address - Fax:801-554-2336
Practice Address - Street 1:4077 S GARY RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2311
Practice Address - Country:US
Practice Address - Phone:801-554-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-10
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT12309986-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator