Provider Demographics
NPI:1508307083
Name:CARLSON, JENNIFER (CMCH MAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CMCH MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8375 S 700 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-0504
Mailing Address - Country:US
Mailing Address - Phone:801-576-0745
Mailing Address - Fax:
Practice Address - Street 1:8375 SOUTH 700EAST
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070
Practice Address - Country:US
Practice Address - Phone:801-576-0745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8336873-6004320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness