Provider Demographics
NPI:1114626496
Name:GARDNER, JEANINE ADERSEN (LCSW)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:ADERSEN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 W IRON GATE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2814
Mailing Address - Country:US
Mailing Address - Phone:801-916-9749
Mailing Address - Fax:
Practice Address - Street 1:151 E 5600 S STE 308
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8102
Practice Address - Country:US
Practice Address - Phone:801-262-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139504-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical