Provider Demographics
NPI:1376758342
Name:BACON, JAIME LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:LEE
Last Name:BACON
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 1:230 N 1680 E
Mailing Address - Street 2:STE T2
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2573
Mailing Address - Country:US
Mailing Address - Phone:435-652-2114
Mailing Address - Fax:435-652-2132
Practice Address - Street 1:230 N 1680 E
Practice Address - Street 2:STE T2
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2573
Practice Address - Country:US
Practice Address - Phone:435-652-2114
Practice Address - Fax:435-652-2132
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361006-35011041C0700X
AZLCSW-110111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical