Provider Demographics
NPI:1194204412
Name:GIFFUNI, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:GIFFUNI
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:PO BOX 1436
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84749-1436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1764 WEST ASPEN LANE
Practice Address - Street 2:
Practice Address - City:LOA
Practice Address - State:UT
Practice Address - Zip Code:84747
Practice Address - Country:US
Practice Address - Phone:435-836-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10269706-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)