Provider Demographics
NPI:1902368640
Name:ELIZABETH, JENNIFER (CMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ELIZABETH
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:ELIZABETH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMHC
Mailing Address - Street 1:1583 S 1600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2829
Mailing Address - Country:US
Mailing Address - Phone:801-636-3029
Mailing Address - Fax:
Practice Address - Street 1:1583 S 1600 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2829
Practice Address - Country:US
Practice Address - Phone:801-636-3029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9656033-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional