Provider Demographics
NPI:1821601758
Name:HARRIS, JESSICA EVA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:EVA
Last Name:HARRIS
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 1:4132 S 700 W
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-1342
Mailing Address - Country:US
Mailing Address - Phone:801-243-2553
Mailing Address - Fax:
Practice Address - Street 1:111 E MAIN ST STE L4
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2490
Practice Address - Country:US
Practice Address - Phone:801-980-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11179303-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical