Provider Demographics
NPI:1639317589
Name:JUESCHKE, JAN (MA)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:
Last Name:JUESCHKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 W SUNSET CREST WAY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7301
Mailing Address - Country:US
Mailing Address - Phone:760-401-3189
Mailing Address - Fax:760-401-3189
Practice Address - Street 1:13552 S 110 W STE 204
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-2403
Practice Address - Country:US
Practice Address - Phone:801-432-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54822106H00000X
UT11360888-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist