Provider Demographics
NPI:1083125694
Name:MARY JANN DEWITT LLC
Entity Type:Organization
Organization Name:MARY JANN DEWITT LLC
Other - Org Name:JANN DEWITT LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANN
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-510-4547
Mailing Address - Street 1:1104 E ASHTON AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2348
Mailing Address - Country:US
Mailing Address - Phone:801-510-4547
Mailing Address - Fax:
Practice Address - Street 1:1104 E ASHTON AVE STE 108
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2348
Practice Address - Country:US
Practice Address - Phone:801-510-4547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT308921-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1487Medicaid