Provider Demographics
NPI:1225193998
Name:MALMBERG, JAN MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:MARIE
Last Name:MALMBERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 AROSA CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1039
Mailing Address - Country:US
Mailing Address - Phone:801-943-5061
Mailing Address - Fax:
Practice Address - Street 1:4214 S 500 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-1336
Practice Address - Country:US
Practice Address - Phone:801-859-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4905206-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11627987OtherCAQH