Provider Demographics
NPI:1073699302
Name:IVERSON, MARY JEAN (CPCI)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JEAN
Last Name:IVERSON
Suffix:
Gender:F
Credentials:CPCI
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JEAN
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:237 26TH STREET
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-3105
Mailing Address - Country:US
Mailing Address - Phone:801-625-3605
Mailing Address - Fax:801-625-3615
Practice Address - Street 1:237 26TH STREET
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3105
Practice Address - Country:US
Practice Address - Phone:801-625-3605
Practice Address - Fax:801-625-3615
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6085774-6009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional