Provider Demographics
NPI:1164485215
Name:ENNISS, JOHN KEVIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KEVIN
Last Name:ENNISS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 S 1300 E # 221
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1817
Mailing Address - Country:US
Mailing Address - Phone:801-867-7170
Mailing Address - Fax:
Practice Address - Street 1:3195 S MAIN ST STE 180
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3790
Practice Address - Country:US
Practice Address - Phone:801-867-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT122189-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical