Provider Demographics
NPI:1972195634
Name:TIETJEN, JULIET PACK (LMFT)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:PACK
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-2540
Mailing Address - Country:US
Mailing Address - Phone:435-760-6769
Mailing Address - Fax:
Practice Address - Street 1:2150 N MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1740
Practice Address - Country:US
Practice Address - Phone:435-554-8647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10853173-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty