Provider Demographics
NPI:1225276611
Name:BOYLE, JEREMY SCOTT (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SCOTT
Last Name:BOYLE
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9055 S 1300 E STE 12
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3190
Mailing Address - Country:US
Mailing Address - Phone:801-657-5312
Mailing Address - Fax:801-653-9663
Practice Address - Street 1:9055 S 1300 E STE 12
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094
Practice Address - Country:US
Practice Address - Phone:801-657-5312
Practice Address - Fax:385-250-2143
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10382604-3902106H00000X, 106H00000X
KSLCMFT 789106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200592530AMedicaid