Provider Demographics
NPI:1922171172
Name:MAGDALEN, JAN R
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:R
Last Name:MAGDALEN
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 1:2071 E ASHTON CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1103
Mailing Address - Country:US
Mailing Address - Phone:801-582-2705
Mailing Address - Fax:801-582-2705
Practice Address - Street 1:2071 E ASHTON CIR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-1103
Practice Address - Country:US
Practice Address - Phone:801-582-2705
Practice Address - Fax:801-582-2705
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT135045-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR61121Medicare UPIN
UT000007722Medicare ID - Type UnspecifiedPROVIDER #