Provider Demographics
NPI:1144767013
Name:BAILEY, JEREMY (LMFT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4559 S LYNN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-5641
Mailing Address - Country:US
Mailing Address - Phone:801-856-8387
Mailing Address - Fax:
Practice Address - Street 1:11762 S STATE ST STE 360
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7166
Practice Address - Country:US
Practice Address - Phone:801-571-6782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10666702-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist