Provider Demographics
NPI:1326020512
Name:JENTZSCH, MABEL ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MABEL
Middle Name:ANN
Last Name:JENTZSCH
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 1:501 E CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1222
Mailing Address - Country:US
Mailing Address - Phone:801-236-7710
Mailing Address - Fax:801-236-7707
Practice Address - Street 1:252 S 500 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2030
Practice Address - Country:US
Practice Address - Phone:801-236-7710
Practice Address - Fax:801-236-7707
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138487-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000075292Medicare PIN
UTU000073742Medicare PIN
UT004662176Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
UTR79715Medicare UPIN