Provider Demographics
NPI:1750020855
Name:JWALKER INTENSIVE OUTPATIENT
Entity Type:Organization
Organization Name:JWALKER INTENSIVE OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-420-3117
Mailing Address - Street 1:503 E 770 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4102
Mailing Address - Country:US
Mailing Address - Phone:801-893-0388
Mailing Address - Fax:
Practice Address - Street 1:503 E 770 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4102
Practice Address - Country:US
Practice Address - Phone:801-893-0388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder