Provider Demographics
NPI:1396715504
Name:CUMBERLAND, MARY JANE (APRN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:CUMBERLAND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:CUMBERLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:22 Q ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3950
Mailing Address - Country:US
Mailing Address - Phone:801-531-6872
Mailing Address - Fax:
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3176
Practice Address - Country:US
Practice Address - Phone:801-539-7000
Practice Address - Fax:801-539-7050
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2177194405363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT003104021OtherRCAR
UT857364OtherU002--DESERET MUTUAL
UTQ39422OtherICAR
UT107029319101OtherU006
UT94293834884101A008OtherU009
UT942938348MJCOtherU003
UT942938348MJCOtherU003
UT003104021Medicare ID - Type Unspecified