Provider Demographics
NPI:1134542582
Name:FAMILYLOVE211
Entity type:Organization
Organization Name:FAMILYLOVE211
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-949-1323
Mailing Address - Street 1:393 EAST RIVERSIDE DR BLDG 3A
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-068-8212
Mailing Address - Fax:
Practice Address - Street 1:393 E RIVERSIDE DR STE 3A
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7127
Practice Address - Country:US
Practice Address - Phone:435-068-8212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3588446004261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health