Provider Demographics
NPI:1356885552
Name:ROSDAHL, JESSIE (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:ROSDAHL
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 S 300 E APT 11
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1606
Mailing Address - Country:US
Mailing Address - Phone:801-822-8452
Mailing Address - Fax:
Practice Address - Street 1:7434 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2014
Practice Address - Country:US
Practice Address - Phone:801-456-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
UT1-17-25435103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst