Provider Demographics
NPI:1619274040
Name:JUNGQUIST, DOUGLAS PAUL (MHC INTERN)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:PAUL
Last Name:JUNGQUIST
Suffix:
Gender:M
Credentials:MHC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N HIGHWAY 89 APT 6L
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-1943
Mailing Address - Country:US
Mailing Address - Phone:440-289-5843
Mailing Address - Fax:
Practice Address - Street 1:411 GRANT ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-2725
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:801-359-8510
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health