Provider Demographics
NPI:1689104309
Name:WIMMER, JAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:WIMMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9645
Mailing Address - Country:US
Mailing Address - Phone:435-770-1429
Mailing Address - Fax:
Practice Address - Street 1:186 E 1800 N
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2019
Practice Address - Country:US
Practice Address - Phone:435-770-1429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT125403-6008101YA0400X
UT125403-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)