Provider Demographics
NPI:1750866265
Name:FERGUSON, CARRIE JO
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:JO
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1359
Mailing Address - Country:US
Mailing Address - Phone:801-272-9980
Mailing Address - Fax:801-272-9976
Practice Address - Street 1:5800 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84121-1359
Practice Address - Country:US
Practice Address - Phone:801-272-9980
Practice Address - Fax:801-272-9976
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT280043-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker