Provider Demographics
NPI:1396719852
Name:JARDINE, MARK (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JARDINE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 STRINGHAM AVE
Mailing Address - Street 2:APT. B310
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3967
Mailing Address - Country:US
Mailing Address - Phone:801-487-0309
Mailing Address - Fax:
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3176
Practice Address - Country:US
Practice Address - Phone:801-536-6523
Practice Address - Fax:801-536-6520
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9113319235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942938348JA3OtherEDUCATORS MUTUAL
UTS56117OtherMEDICARE ADVANTAGE PLANS
UT107001377101OtherINTERMOUNTAIN HEALTH CARE
UT261909OtherDESERET MUTUAL
UT942938348JA3OtherEDUCATORS MUTUAL