Provider Demographics
NPI:1548568371
Name:SHIRLEY, JENNA LEE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LEE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3983 S 855 E
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2366
Mailing Address - Country:US
Mailing Address - Phone:801-734-0581
Mailing Address - Fax:
Practice Address - Street 1:1290 S 500 W STE 300
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-8104
Practice Address - Country:US
Practice Address - Phone:801-734-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT9455954-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator