Provider Demographics
NPI:1851822464
Name:FISHER CHAMPLIN, JESSICA LACEY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LACEY
Last Name:FISHER CHAMPLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LACEY
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:553 N 190 E
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2200
Mailing Address - Country:US
Mailing Address - Phone:801-215-9575
Mailing Address - Fax:833-904-1668
Practice Address - Street 1:1290 S 500 W STE 300
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-8104
Practice Address - Country:US
Practice Address - Phone:801-215-9575
Practice Address - Fax:833-904-1668
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10853410-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical