Provider Demographics
NPI:1376288043
Name:GOSSNER, JACOB DARIUS (LAMFT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DARIUS
Last Name:GOSSNER
Suffix:
Gender:M
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 N 420 W APT 101
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-4068
Mailing Address - Country:US
Mailing Address - Phone:801-564-4024
Mailing Address - Fax:
Practice Address - Street 1:175 W 1400 N STE A
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-6816
Practice Address - Country:US
Practice Address - Phone:435-752-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12745274-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist