Provider Demographics
NPI:1235980053
Name:WELCH-STOCKTON, JESSIE LIWANU (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LIWANU
Last Name:WELCH-STOCKTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7621 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7392
Mailing Address - Country:US
Mailing Address - Phone:208-994-2226
Mailing Address - Fax:
Practice Address - Street 1:555 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1106
Practice Address - Country:US
Practice Address - Phone:801-585-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10941331-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical