Provider Demographics
NPI:1942666870
Name:BOBERG, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BOBERG
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 1:2590 E PRAIRIE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-6096
Mailing Address - Country:US
Mailing Address - Phone:801-634-8938
Mailing Address - Fax:801-766-1940
Practice Address - Street 1:2590 E PRAIRIE VIEW DR
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-6096
Practice Address - Country:US
Practice Address - Phone:801-634-8938
Practice Address - Fax:801-766-1940
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5829317-6008101YA0400X
UT5829317-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)