Provider Demographics
NPI:1619529500
Name:BLACK, JESSICA DAWN (ACMHC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:BLACK
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5398 S 1345 W
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4000
Mailing Address - Country:US
Mailing Address - Phone:801-209-1212
Mailing Address - Fax:
Practice Address - Street 1:1576 S 500 W
Practice Address - Street 2:SUITE 102
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-406-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11070400-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health