Provider Demographics
NPI:1164709671
Name:JEWELL, JESSICA DAWN (MS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:JEWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-0259
Mailing Address - Country:US
Mailing Address - Phone:801-633-6094
Mailing Address - Fax:
Practice Address - Street 1:2065 SIDEWINDER DR
Practice Address - Street 2:STE. 102
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7216
Practice Address - Country:US
Practice Address - Phone:801-633-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7091340-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional