Provider Demographics
NPI:1578506697
Name:BURTON, JAN ELLEN KADERABEK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAN ELLEN
Middle Name:KADERABEK
Last Name:BURTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2600
Mailing Address - Country:US
Mailing Address - Phone:801-274-0403
Mailing Address - Fax:
Practice Address - Street 1:4190 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2600
Practice Address - Country:US
Practice Address - Phone:801-274-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1103862501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107009442101OtherINTERMOUNTAIN HEALTH CARE
UT261736OtherDESERET MUTUAL
UT942938348BU1OtherEDUCATORS MUTUAL
UTR34233Medicare UPIN