Provider Demographics
NPI:1568991628
Name:REYES, JEAN RODRIGUEZ (REGISTERED BEHAVIOR)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:RODRIGUEZ
Last Name:REYES
Suffix:
Gender:F
Credentials:REGISTERED BEHAVIOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 N 150 W
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5829
Mailing Address - Country:US
Mailing Address - Phone:385-319-0395
Mailing Address - Fax:
Practice Address - Street 1:5974 FASHION POINT DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4840
Practice Address - Country:US
Practice Address - Phone:801-655-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17-34886106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician