Provider Demographics
NPI:1639441058
Name:ANDERSEN, JESSICA SHAW (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHAW
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 S 175 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5566
Mailing Address - Country:US
Mailing Address - Phone:801-822-2699
Mailing Address - Fax:
Practice Address - Street 1:210 N 1200 E
Practice Address - Street 2:SUITE 205
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2297
Practice Address - Country:US
Practice Address - Phone:801-822-2699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6235427-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health