Provider Demographics
NPI:1093312746
Name:CARLSON, JERICHO
Entity Type:Individual
Prefix:
First Name:JERICHO
Middle Name:
Last Name:CARLSON
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 1:3006 S HIGHLAND DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-6004
Mailing Address - Country:US
Mailing Address - Phone:801-647-3920
Mailing Address - Fax:
Practice Address - Street 1:3006 S HIGHLAND DR STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-6004
Practice Address - Country:US
Practice Address - Phone:801-647-3920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician